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Intermittent aortic regurgitation in a case of mechanical prosthesis dysfunction
International Journal of Cardiology 102 (2005) 525 – 527 www.elsevier.com/locate/ijcard
Letter to the Editor
Intermittent aortic regurgitation in a case of mechanical prosthesis dysfunction Pablo Robles*, Jose Julio Jimenez Nacher, Amador Rubio, Ana Huelmos, Lorenzo Lopez Fundacio´n Hospital Alcorco´n, Cardiology, Alcorcon, Madrid, Spain Received 9 May 2004; accepted 19 June 2004 Available online 28 January 2005
Keywords: Aortic regurgitation; Prosthesis; Dysfunction
Dysfunction of any mechanical prosthesis due to thrombus or pannus requires prompt definite diagnosis and therapy. A 52-year-old man had received a Medtronic Hall prosthetic valve for aortic regurgitation 10 years before and was admitted for intermittent chest pain. Electrocardiography showed atrial fibrilation and no remarkable ST depression in broad or precordial leads. The troponin level was 2. The international normalized ratio on admission was 3.2. On reviewing her anticoagulation chart, the lowest international normalized ratio since her operation was 2.2 which was 2 weeks before admission. He was apyrexial, her pulse was regular at 92 bpm, and her blood pressure was 140/70 mmHg. On auscultation her prosthetic clicks could be heard intermittently. A systolic murmur consistent with severe aortic stenosis was also heard. No diastolic murmur was heard. There were no signs of cardiac failure. Routine hematologic and biochemical indexes were normal. Transesophageal echocardiography did not show any mass on the valve prosthesis and movements of the prosthesis are normal aparent. A detailed transthoracic echocardiography confirmed that the aortic valve prosthesis was malfunctioning; severe obstructive gradients (max 100 mmHg; med 70 mmHg) could be readily demonstrated on spectral (Fig. 1) flow Doppler imaging. In all the cycles the signal of
* Corresponding author. c/Don˜a Mariquita la Mu´sica no_ 34, 28903 Getafe (Madrid) Spain. Tel.: +34 91 6817330; fax: +34 91 6219901. E-mail address: [email protected] (P. Robles). 0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2004.06.013
the closing prosthesis can be seen delayed and a jet of short duration contrary to forward systolic flow was possible to visualize. This image corresponds to minimal aortic regurgitation. In other beats it was possible to observe like the prosthesis showed severe intermittent aortic regurgitation on spectral (Fig. 2) Doppler imaging caused by the disk sticking in the open position for several cardiac cycles. Abnormal proliferation of pannus trapping the artificial aortic valve was found at the left ventricular-side orifice of the prosthetic valve. Intermittent valvular sticking can cause acute aortic regurgitation and caused the symptomatic intermittent chest pain. consistent with thrombus. After discussion with the cardiac surgeons, a decision was made to treat the patient with surgical treatment. The surgery confirmed the pannus. Phrostetic valve dysfunction as a result of pannus formation is an infrequent but serious complication. However, the mechanism of pannus formation has not been fully proven yet [1]. The echocardiography is the diagnostic method of diagnosis but artifacts resulting from leaflet movement and lower resolution of the ultrasonic image may interfere with detailed observations of periannular morphology [2]. Our case demonstrates that prosthetic valve malfunction may be intermittent and therefore may not be apparent at the time of clinical examination [3]. In such patients cardiac auscultation should be much longer than usual, and specific instructions must be given to the echocardiographer to scan and Doppler interrogate the suspected prosthetic valve continuously for an extended period [4].
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P. Robles et al. / International Journal of Cardiology 102 (2005) 525–527
Fig. 1. Continous spectral Doppler trace shows prosthetic valve obstruction. The arrow shows the signals (vertical lines) generated by prosthetic valve opening and closure. In this spectrum the signal of the closing prosthesis can be seen delayed and a jet of short duration contrary to forward systolic flow was possible to visualize.
Fig. 2. Continous spectral Doppler or the same patient showed severe intermittent aortic caused by the disk sticking in the open position for several cardiac cycles. The arrow shows the triangular velocity profile of severe aortic regurgitation. In these beats, closing signals cannot be seen and the valve stays open causing free aortic regurgitation.
P. Robles et al. / International Journal of Cardiology 102 (2005) 525–527
References [1] 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. [2] 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.
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[3] Dzavik V, Cohen G, Chan KL. Role of transesophageal echocardiography in the diagnosis and management of prosthetic valve thrombosis. J Am Coll Cardiol 1991;18:1829 – 33. [4] Rittoo Dylmitr, Buckley Helen, Cotter Lawrence. Recurrent prosthetic valve thrombosis: importance of prolonged Doppler echocardiography examination for diagnosis. J Am Soc Echocardiogr 1992;12:686 – 8.
Letter to the Editor
Intermittent aortic regurgitation in a case of mechanical prosthesis dysfunction Pablo Robles*, Jose Julio Jimenez Nacher, Amador Rubio, Ana Huelmos, Lorenzo Lopez Fundacio´n Hospital Alcorco´n, Cardiology, Alcorcon, Madrid, Spain Received 9 May 2004; accepted 19 June 2004 Available online 28 January 2005
Keywords: Aortic regurgitation; Prosthesis; Dysfunction
Dysfunction of any mechanical prosthesis due to thrombus or pannus requires prompt definite diagnosis and therapy. A 52-year-old man had received a Medtronic Hall prosthetic valve for aortic regurgitation 10 years before and was admitted for intermittent chest pain. Electrocardiography showed atrial fibrilation and no remarkable ST depression in broad or precordial leads. The troponin level was 2. The international normalized ratio on admission was 3.2. On reviewing her anticoagulation chart, the lowest international normalized ratio since her operation was 2.2 which was 2 weeks before admission. He was apyrexial, her pulse was regular at 92 bpm, and her blood pressure was 140/70 mmHg. On auscultation her prosthetic clicks could be heard intermittently. A systolic murmur consistent with severe aortic stenosis was also heard. No diastolic murmur was heard. There were no signs of cardiac failure. Routine hematologic and biochemical indexes were normal. Transesophageal echocardiography did not show any mass on the valve prosthesis and movements of the prosthesis are normal aparent. A detailed transthoracic echocardiography confirmed that the aortic valve prosthesis was malfunctioning; severe obstructive gradients (max 100 mmHg; med 70 mmHg) could be readily demonstrated on spectral (Fig. 1) flow Doppler imaging. In all the cycles the signal of
* Corresponding author. c/Don˜a Mariquita la Mu´sica no_ 34, 28903 Getafe (Madrid) Spain. Tel.: +34 91 6817330; fax: +34 91 6219901. E-mail address: [email protected] (P. Robles). 0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2004.06.013
the closing prosthesis can be seen delayed and a jet of short duration contrary to forward systolic flow was possible to visualize. This image corresponds to minimal aortic regurgitation. In other beats it was possible to observe like the prosthesis showed severe intermittent aortic regurgitation on spectral (Fig. 2) Doppler imaging caused by the disk sticking in the open position for several cardiac cycles. Abnormal proliferation of pannus trapping the artificial aortic valve was found at the left ventricular-side orifice of the prosthetic valve. Intermittent valvular sticking can cause acute aortic regurgitation and caused the symptomatic intermittent chest pain. consistent with thrombus. After discussion with the cardiac surgeons, a decision was made to treat the patient with surgical treatment. The surgery confirmed the pannus. Phrostetic valve dysfunction as a result of pannus formation is an infrequent but serious complication. However, the mechanism of pannus formation has not been fully proven yet [1]. The echocardiography is the diagnostic method of diagnosis but artifacts resulting from leaflet movement and lower resolution of the ultrasonic image may interfere with detailed observations of periannular morphology [2]. Our case demonstrates that prosthetic valve malfunction may be intermittent and therefore may not be apparent at the time of clinical examination [3]. In such patients cardiac auscultation should be much longer than usual, and specific instructions must be given to the echocardiographer to scan and Doppler interrogate the suspected prosthetic valve continuously for an extended period [4].
526
P. Robles et al. / International Journal of Cardiology 102 (2005) 525–527
Fig. 1. Continous spectral Doppler trace shows prosthetic valve obstruction. The arrow shows the signals (vertical lines) generated by prosthetic valve opening and closure. In this spectrum the signal of the closing prosthesis can be seen delayed and a jet of short duration contrary to forward systolic flow was possible to visualize.
Fig. 2. Continous spectral Doppler or the same patient showed severe intermittent aortic caused by the disk sticking in the open position for several cardiac cycles. The arrow shows the triangular velocity profile of severe aortic regurgitation. In these beats, closing signals cannot be seen and the valve stays open causing free aortic regurgitation.
P. Robles et al. / International Journal of Cardiology 102 (2005) 525–527
References [1] 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. [2] 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.
527
[3] Dzavik V, Cohen G, Chan KL. Role of transesophageal echocardiography in the diagnosis and management of prosthetic valve thrombosis. J Am Coll Cardiol 1991;18:1829 – 33. [4] Rittoo Dylmitr, Buckley Helen, Cotter Lawrence. Recurrent prosthetic valve thrombosis: importance of prolonged Doppler echocardiography examination for diagnosis. J Am Soc Echocardiogr 1992;12:686 – 8.