Ann Thorac Surg 2009;88:996-998. doi:10.1016/j.athoracsur.2009.01.038
© 2009 The Society of Thoracic Surgeons
Case Reports
Recurrent Pulmonary Edema in a Patient With a Prosthetic Mitral Valve
Joris Schurmans, MDa,*,
Bert Ferdinande, MDa,
Siegmund Keuleers, MDa,
Paul Herijgers, MD, PhDb,
Werner Budts, MD, PhDa
a Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
b Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
Accepted for publication January 13, 2009.
* Address correspondence to Dr Schurmans, Department of Cardiology, University Hospitals Leuven, Herestraat, Leuven, 49 B-3000, Belgium (Email: joris.schurmans{at}uz.kuleuven.ac.be).
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Abstract
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Prosthetic heart valve obstruction is a severe and potentially fatal complication. We present a patient with a Bjork-Shiley prosthetic mitral and aortic valve implantation and recurrent pulmonary edema. Echocardiogram showed a rate-dependent "obstruction alternans" of the prosthetic mitral valve due to pannus formation.
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Introduction
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Prosthetic heart valve obstruction (PHVO) is caused by valve thrombosis, pannus formation on the valve, or the combination of both. Treatment mostly consists in valve re-replacement. Less frequently, clot removing or pannus excision is performed. Thrombolysis might be used in thrombus-induced PHVO.
A 70-year-old woman with an aortic and mitral valve replacement (both Bjork-Shiley valves), 27 years ago and recently paroxysmal atrial fibrillation was referred with severe pulmonary edema. At admission, atrial fibrillation with rapid ventricular response was present. Anticoagulation therapy was adequate. She was successfully treated with amiodarone and intravenous diuretics, and she was converted to sinus rhythm. Transthoracic and transesophageal echocardiogram, which were performed in sinus rhythm, both showed a good left ventricular function and normal mobility of the mechanical valve leaflets, without apparent thrombus. Normal function of the valve leaflets was confirmed by fluoroscopy. Atrial fibrillation with rapid ventricular response was withheld as the underlying cause of congestive heart failure, and the patient was transferred for rehabilitation.
A few days later, she had severe heart failure develop again, but this time with a small QRS tachycardia of 130 bpm. Oxygen, intravenous diuretics, and nitrates led to conversion to sinus rhythm. An arterial line was inserted in the radial artery and a pulse deficit was detected (Fig 1A). Auscultation suggested an intermittent absence of prosthetic mitral valve sounds. New transthoracic and transesophageal echocardiograms were performed, showing a mildly impaired left ventricular systolic function with intermittent nonopening of the mitral prosthetic valve leaflets (ratio 1:2–1:3; obstruction alternans) (Fig 1B), and an alternating increase and drop of transmitral gradients. Shortly afterward, a 1-minute episode of continuous closure of the mitral prosthetic valve occurred with no cardiac output. Adrenalin and intravenous fluids were administrated with partial recuperation of the mitral valve function (opening ratio 2:3). All this suggested an intermittent severe mitral valve dysfunction; the patient was referred for urgent surgery.
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Fig 1. (A) Simultaneous electrocardiogram and radial pressure curve recordings showing a sinus rhythm with rate of 94 bpm (upper panel) with intermittent pulse pressure drop (arrow) from plus minus 170 to 133 mm Hg in a 1:2 ratio (lower panel). (B) Continuous wave Doppler (transthoracic echocardiogram) recordings through the mitral valve prosthesis (Bjork-Shiley) showing "obstruction alternans" pattern of low-intensity prosthetic valve opening-closing signal (gray double arrow) with (near) absence of diastolic mitral valve flow (vertical arrow) alternated with the (normal) high-intensity prosthetic valve opening-closing signal (white double arrow), with increased mitral valve flow velocities (obstructive flow) (horizontal arrow). Electrocardiographic recordings (bottom) show a sinus rhythm of 90 bpm. (C) Continuous wave Doppler (transthoracic echocardiography) through the mitral valve prosthesis (Bjork-Shiley) showing normal function and gradient.
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Perioperative inspection of the mitral valve documented an important fibrous overgrowth (Fig 2A) on the atrial and ventricular side, as well as a small thrombus, located posteriorly between the overgrowth and the prosthetic valve struts. Dental mirrors, hooked curettes, and rongeurs were used to assure complete removal of ventricular pannus and thrombus, so that the mechanical valve could be left in situ (Figs 2B and 2C). Transthoracic echocardiogram 1 week after surgery showed a normal function of the prosthetic mitral valve (Fig 1C).
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Fig 2. (Panel A) Perioperative view of the Bjork-Shiley mechanical mitral valve with fibrous overgrowth (arrow). (Panel B) Perioperative view of the Bjork-Shiley mechanical mitral valve after removing fibrous overgrowth. (Panel C) Surgically removed circumferential fibrous overgrowth.
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Comment
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Prosthetic heart valve obstruction is a severe and potentially fatal complication with obstruction caused by thrombosis, pannus formation, or the combination of both. Suspected diagnosis can be confirmed by transthoracic echocardiography, transesophageal echocardiography, and fluoroscopy and cineangiography [1].
Thrombosis is related to the deposition of clots on the prosthesis, while pannus formation occurs as the result of an inflammatory reaction on both valve surfaces. Vitale and colleagues [2] described a series of 87 patients with mitral valve obstruction in which pannus formation was present at the atrial site in 19.7%, at the ventricular site in 21.2%, and at both sites in 59.1% of the cases. Secondary thrombi occurred more often in patients with atrioventricular pannus, which might also be the only cause of valve obstruction (11%–71%) [3–4].
While valve thrombosis seems to occur at random, with inadequate anticoagulation as the most important determinant in the pathogenesis [5], pannus formation requires a larger time period and seems to show a delayed exponential increase [2–5].
Surgical mortality for PHVO is higher in patients with thrombus obstruction compared with those who have pannus formation. The latter is probably related to the emergency condition as the result of an acute hemodynamic deterioration by clot formation [6]. Therefore, thrombolysis might be a good and effective alternative in patients with thrombus-induced prosthetic heart valve obstruction [7]. The operative procedure consists mostly of valve re-replacement. Less frequently, clot removing or pannus excision is performed, which was done in our patient [8]. However, recurrence of pannus formation in these patients remains unpredictable.
In our case, PHVO occurred 27 years after mitral valve implantation, with the formation of atrioventricular pannus and a secondary thrombus. What made our case particularly interesting from a diagnostic point of view was that (at least initially) PHVO seemed to be dynamic and rate and rhythm dependent. This led to an initial misdiagnosis of atrial fibrillation with rapid ventricular response as the primary cause of the pulmonary edema, because evaluation in sinus rhythm with slow ventricular response showed no abnormal prosthetic mitral valve function.
In conclusion, we would like to stress that in patients with prosthetic heart valves presenting with an episode of congestive heart failure, the possibility of PHVO as an underlying cause should always be considered, even with adequate anticoagulation. Prosthetic heart valve obstruction remains a severe and life-threatening complication. Diagnosis is possible by transthoracic and transesophageal echocardiograms or fluoroscopy, but it may be particularly difficult when PHVO is rate and rhythm dependent, as it was initially in our case.
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References
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- Vitale N, Renzulli A, Agozzino L, et al. Obstruction of mechanical mitral prostheses: analysis of pathological findings Ann Thorac Surg 1997;63:1101-1106.[Abstract/Free Full Text]
- Toker ME, Eren E, Balkanay M, et al. Multivariate analysis for operative mortality in obstructive prosthetic valve dysfunction duet o pannus and thrombus formation Int Heart J 2006;47:237-245.[Medline]
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- Bortolotti U, Milano A, Mossuto E, Mazzaro E, Thiene G, Casarotto D. Early and late outcome after reoperation for prosthetic valve dysfunction: analysis of 549 patients during a 26-year period J Heart Valve Dis 1994;3:81-87.[Medline]
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- Roudaut R, Roques X, Lafitte S, et al. Surgery for prosthetic valve obstruction. A single center study of 136 patients. Eur J Cardiothorac Surg 2003;24:868-872.[Abstract/Free Full Text]
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Abstract
Introduction
