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Ann Thorac Surg 2009;87:e50. doi:10.1016/j.athoracsur.2009.02.044
© 2009 The Society of Thoracic Surgeons
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Images in Cardiothoracic Surgery

Dual-Source Computed Tomography Assessment of Malfunctioning Mechanical Prosthetic Valve

Gorka Bastarrika, MD, PhDa,b, William W. Brabham, MDc, Terrence X. O'Brien, MDc, Philip Costello, MDa, U. Joseph Schoepf, MDa,c,*

a Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina
c Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
b Department of Radiology, University of Navarra, Pamplona, Spain

* Address correspondence to Dr Schoepf, Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Dr, MSC 226, Charleston, SC 29401 (Email: schoepf{at}musc.edu).

A 41-year-old woman was admitted to the Medical University of South Carolina cardiology service with new-onset atrial fibrillation, with chest tightness, shortness of breath, and a nonproductive cough. As a child, she had a congenital bicuspid aortic valve with severe aortic stenosis that initially required commissurotomy, a bioprosthetic valve replacement at age 10, and a St. Jude mechanical valve (St. Jude Medical, St. Paul, MN) replacement at age 12. She had never received anticoagulant therapy other than aspirin, originally as part of a research protocol, subsequently because of pregnancies and then through loss of follow-up.

On admission, her blood pressure was 100/85 mm Hg with an irregular pulse of 125 beats/min. The physical examination was notable for a 2/6 systolic ejection murmur, with a crisp click at valve closure. Transthoracic echocardiography demonstrated respective peak and mean aortic valve gradients of 62 and 40 mm Hg, incomplete valve visualization, preserved left ventricular function, and an enlarged left atrium (5.8 cm). Fluoroscopy revealed the posterior leaflet was fixed in the open position.

A contrast-enhanced, electrocardiographically synchronized dual-source cardiac computed tomography study was ordered to determine the cause of the valve dysfunction, specifically to differentiate pannus from thrombus. The examination demonstrated that thrombus (arrowheads) between the posterior leaflet of the aortic valve and the aortic ring was causing mechanical valve failure (Fig 1). The posterior leaflet was stuck in an open position in systole (upper row) and diastole (lower row). This functional abnormality was better demonstrated using multiplanar reformations visualized in oblique coronal views (A, B), transverse views (C, D), and at 3-dimensional volume-rendered reconstructions (E, F).


Figure 1
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  		Fig 1.
 
Because of the finding of valvular thrombosis and the attendant high risk of a fourth open heart procedure, thrombolytics were administered (a full dose of tissue plasminogen activator during a 2-hour period).

After treatment, fluoroscopy in multiple views showed normal bileaflet function of the mechanical aortic valve. The mean pressure gradient across the prosthetic aortic valve decreased to 20 mm Hg. Her atrial fibrillation was rate controlled and spontaneously converted. The patient was instructed to remain on life-long anticoagulant therapy with warfarin.

Fluoroscopy remains one of the first-line tests for assessing prosthetic valves, but can only diagnose presence or absence of mechanical malfunction. This case illustrates that cardiac computed tomography, because of its contrast resolution and cross-sectional nature, can be a useful second-line problem-solving tool to elucidate the cause of prosthetic valve failure.





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