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Intermittent regurgitation flow with Björk-Shiley mitral prosthesis in atrial fibrillation
1006
Bodur and Friart
American
October 19% Heart Journai
Dunn RP. Primary chylopericardium: a review of the literatureand an illustrated case.AM HEARTJ 1975;89:369-77. 4. Bakay C, Wijers TS. Treatment of cardiactamponade due to isolated chylopericardium following open-heart surgery. J CardiovascSurg 1984;25:249-51. 5. Jalili F. Medium-chain triglycerides and total parenteral nutrition in the management of ingants with congenital chylothorax. South Med J 1987;80:1290-3. 6. SelleJG, Snyder WH III, SchreiberJT. Chylothorax: indication for surgery. Ann Surg 1972;177:245-9. 3.
lntermittelnt reguigitation flow with Bj(Srl&hiley mitral prosthesis in atrial fibrillation Giikhan Bodur, MD, and Alain Friart, MD La Louviere,
Belgium
Partial mitral valve closure in atrial fibrillation can be observed with normally functioning mitral prosthesis during long diastole.ia 2 This is considered a curiosity without any consequence. We report a case where partial mitral valve closure seems to induce pathologic regurgitation. The clear demonstration and understanding of the mechanism was possible only by transesophageal color Doppler flow imaging, which is considered an extremely sensitive method for the detection of mitral regurgitation, especially with mechanical prosthesis.2-4 A 48-year-old man was admitted in our intensive care unit because of congestive heart failure. At age 31 years, he underwent a replacement of the mitral valve by a BjorkShiley mechanical prosthesis because of severe calcified stenosis. Despite normal functioning of the prosthesis, progressive deterioration of the left ventricular systolic function was observed. Two days before his admission he described episodic palpitations and aggravation of dyspnea without chest pain. At admission he showed signs of congestive heart failure with general edema, dyspnea at rest, and asthenia. At auscultation, sounds of prosthetic valve were audible, and no abnormality was noticed. The electrocardiogram (ECG) showed atria1 fibrillation. A transthoracic echocardiographic study carried out immediately showed poor left ventricular systolic function and an enlarged left atrium. No prosthetic mitral valve abnormal-
From
Centre
Hospitalier
Reprint requests: Alain Hospitalier Universitaire Louviere, Belgium. AM HEARTJ
Universitaire Friart, MD, de Tivoli,
de Tivoli,
La Louviere.
Department of Cardiology, Centre Avenue Max Buset, 34, 7100 La
1993;126:1006-1007.
Copyright @ 1993 by Mosby-Year Book, 0002-8703/93/$1.00 + .lO 4/4/48525
Inc.
Fig. 1. Transesophageal color Doppler flow images of Bjork-Shiley prosthesis in atria1 fibrillation with slight regurgitation jet after short diastole (A); pathologic regurgitation after long diastole (B). LA, Left atrium;. LV, left ventricle.
ity was detected at M-mode and B-mode study. At Doppler study, furmtioning of the mitral prosthesis seemed to be normal (pressure half-time was approximately 80 msec; transvalvular maximum and mean gradient were 15 mm Hg and 4 mm Hg, respectively) but multiple reverberating echoes prevented us from having good analysis in color Doppler. We performed a transesophageal echocardiographic study while the patient was still in atrial fibrillation. We noticed two regurgitation fluxes (‘Fig. 1); the first was slight and considered normal 5,6 for this mechanical prosthesis, but episodically a second important eccentric and whole left atrium filling regurgitation was observed. After analysis we concluded’ that this second regurgitation was appearing only during sgstole, which was following a long diastole with middiastalic partial mitral valve closure (Figs. 2 and 3). It was not paravalvular, and there was neither thrombus nor vegetation on this prosthesis. We did not notice this abnormal regurgitation after short diastole and on the second examination performed after sinus rhythm was restored.
Volume 126, Number 4 American Heart Journal
Bodur and Friart
1007
Fig. 3. Transesophageal continuous wave Doppler image of same prosthesis in atria1 fibrillation. Second diastole is long and shows jerky closure movement (arrow) instead of unique closure click and followed by abnormal mitral regurgitation (MR).
Fig. 2. Transesophageal M-mode and color M-mode images of Bjark-Shiley prosthesis in atrial fibrillation. A, First diastole is long and shows normal opening of the disc, partial middiastolic (arrow) and premature closure before R wave (triangle) in long diastole, with decrease of closure slope of mitral prosthesis. Second diastole is short with normal opening and closure pattern of disc. B, Abnormal regurgitation jet (MR) after long diastole, with complete absence of closure click. After second diastole (a short one), closure click is normal (arrow) and not followed by pathologic MR. MR, Mitral regurgitation.
gitation, but we were surprised by its importance in color Doppler. In summary, we describe a case in which partial closure of a mitral mechanical prosthesis (which is considered a normal finding for this kind of prosthesis in long diastole in atrial fibrillation) is responsible for pathologic regurgitation. On the contrary, after short diastole or in sinus rhythm this old prosthesis functions normally. REFERENCES
1.
2.
Our patient had an old BjBrk-Shiley prosthesis with intermittent pathologic regurgitation that appeared only after a long diastole in atria1 fibrillation. These long diastoles caused partial mitral valve closure. 1,2 After this common finding, the systolic closure movement of the disc was reduced, and probably accumulation of fibrin on this old prosthesis prevented the correct closure of the disc and induced pathologic regurgitation. However, the amplitude of the closure movement of the disc was normal, and only slight (normal) regurgitation was observed in sinus rhythm or after short diastole in atrial fibrillation. A comparison can be made with an old door that needs to be banged with large closure movement for correct closure. We ignored the hemodynamic consequence of this pathologic mitral regur-
3.
4.
5.
6.
Kotler N, Mintz G, Panidis I, Morganroth
J, Segal B, Ross J. Non invasive evaluation of normal and abnormal prosthetic valve function. J Am Co11 Cardiol 1983;2:151-73. Brockman S. Mechanism of the movements of atrioventricular valves. Am J Cardiol 1966;17:682-90. Taams M, Gussenhoven E, Cahalan M, Roelandt J, Van Herwerden L, The H, Born N, De Jong N. Transesophageal Doppler color flow imaging in the detection of native and Bj(jrkShiley mitral valve regurgitation. J Am Co11 Cardiol 1989; 13:95-g. Vandenbrink R, Visser C, Basart D, Duren D, De Jong A, Dunning A. Comparison of transthoracic and transesophageal color Doppler flow imaging in patients with mechanical prosthesis in the mitral valve nosition. Am J Cardiol1989;63:147174. Sagar K, Wann S, Paulsen W, Romhilt D. Doppler echocardiographic evaluation of Hancock and Bjsrk Shiley prosthetic valves. J Am Co11 Cardiol 1986;7:681-9. Rashtiaw M, Stevenson D, Allen D. Earl Y, Harrison E, Edmiston A, Faughan P, Rahimtoola &. Flow characteristics of four commonlv used mechanical heart valves. Am J Cardiol 1986;58:743-5i.
Bodur and Friart
American
October 19% Heart Journai
Dunn RP. Primary chylopericardium: a review of the literatureand an illustrated case.AM HEARTJ 1975;89:369-77. 4. Bakay C, Wijers TS. Treatment of cardiactamponade due to isolated chylopericardium following open-heart surgery. J CardiovascSurg 1984;25:249-51. 5. Jalili F. Medium-chain triglycerides and total parenteral nutrition in the management of ingants with congenital chylothorax. South Med J 1987;80:1290-3. 6. SelleJG, Snyder WH III, SchreiberJT. Chylothorax: indication for surgery. Ann Surg 1972;177:245-9. 3.
lntermittelnt reguigitation flow with Bj(Srl&hiley mitral prosthesis in atrial fibrillation Giikhan Bodur, MD, and Alain Friart, MD La Louviere,
Belgium
Partial mitral valve closure in atrial fibrillation can be observed with normally functioning mitral prosthesis during long diastole.ia 2 This is considered a curiosity without any consequence. We report a case where partial mitral valve closure seems to induce pathologic regurgitation. The clear demonstration and understanding of the mechanism was possible only by transesophageal color Doppler flow imaging, which is considered an extremely sensitive method for the detection of mitral regurgitation, especially with mechanical prosthesis.2-4 A 48-year-old man was admitted in our intensive care unit because of congestive heart failure. At age 31 years, he underwent a replacement of the mitral valve by a BjorkShiley mechanical prosthesis because of severe calcified stenosis. Despite normal functioning of the prosthesis, progressive deterioration of the left ventricular systolic function was observed. Two days before his admission he described episodic palpitations and aggravation of dyspnea without chest pain. At admission he showed signs of congestive heart failure with general edema, dyspnea at rest, and asthenia. At auscultation, sounds of prosthetic valve were audible, and no abnormality was noticed. The electrocardiogram (ECG) showed atria1 fibrillation. A transthoracic echocardiographic study carried out immediately showed poor left ventricular systolic function and an enlarged left atrium. No prosthetic mitral valve abnormal-
From
Centre
Hospitalier
Reprint requests: Alain Hospitalier Universitaire Louviere, Belgium. AM HEARTJ
Universitaire Friart, MD, de Tivoli,
de Tivoli,
La Louviere.
Department of Cardiology, Centre Avenue Max Buset, 34, 7100 La
1993;126:1006-1007.
Copyright @ 1993 by Mosby-Year Book, 0002-8703/93/$1.00 + .lO 4/4/48525
Inc.
Fig. 1. Transesophageal color Doppler flow images of Bjork-Shiley prosthesis in atria1 fibrillation with slight regurgitation jet after short diastole (A); pathologic regurgitation after long diastole (B). LA, Left atrium;. LV, left ventricle.
ity was detected at M-mode and B-mode study. At Doppler study, furmtioning of the mitral prosthesis seemed to be normal (pressure half-time was approximately 80 msec; transvalvular maximum and mean gradient were 15 mm Hg and 4 mm Hg, respectively) but multiple reverberating echoes prevented us from having good analysis in color Doppler. We performed a transesophageal echocardiographic study while the patient was still in atrial fibrillation. We noticed two regurgitation fluxes (‘Fig. 1); the first was slight and considered normal 5,6 for this mechanical prosthesis, but episodically a second important eccentric and whole left atrium filling regurgitation was observed. After analysis we concluded’ that this second regurgitation was appearing only during sgstole, which was following a long diastole with middiastalic partial mitral valve closure (Figs. 2 and 3). It was not paravalvular, and there was neither thrombus nor vegetation on this prosthesis. We did not notice this abnormal regurgitation after short diastole and on the second examination performed after sinus rhythm was restored.
Volume 126, Number 4 American Heart Journal
Bodur and Friart
1007
Fig. 3. Transesophageal continuous wave Doppler image of same prosthesis in atria1 fibrillation. Second diastole is long and shows jerky closure movement (arrow) instead of unique closure click and followed by abnormal mitral regurgitation (MR).
Fig. 2. Transesophageal M-mode and color M-mode images of Bjark-Shiley prosthesis in atrial fibrillation. A, First diastole is long and shows normal opening of the disc, partial middiastolic (arrow) and premature closure before R wave (triangle) in long diastole, with decrease of closure slope of mitral prosthesis. Second diastole is short with normal opening and closure pattern of disc. B, Abnormal regurgitation jet (MR) after long diastole, with complete absence of closure click. After second diastole (a short one), closure click is normal (arrow) and not followed by pathologic MR. MR, Mitral regurgitation.
gitation, but we were surprised by its importance in color Doppler. In summary, we describe a case in which partial closure of a mitral mechanical prosthesis (which is considered a normal finding for this kind of prosthesis in long diastole in atrial fibrillation) is responsible for pathologic regurgitation. On the contrary, after short diastole or in sinus rhythm this old prosthesis functions normally. REFERENCES
1.
2.
Our patient had an old BjBrk-Shiley prosthesis with intermittent pathologic regurgitation that appeared only after a long diastole in atria1 fibrillation. These long diastoles caused partial mitral valve closure. 1,2 After this common finding, the systolic closure movement of the disc was reduced, and probably accumulation of fibrin on this old prosthesis prevented the correct closure of the disc and induced pathologic regurgitation. However, the amplitude of the closure movement of the disc was normal, and only slight (normal) regurgitation was observed in sinus rhythm or after short diastole in atrial fibrillation. A comparison can be made with an old door that needs to be banged with large closure movement for correct closure. We ignored the hemodynamic consequence of this pathologic mitral regur-
3.
4.
5.
6.
Kotler N, Mintz G, Panidis I, Morganroth
J, Segal B, Ross J. Non invasive evaluation of normal and abnormal prosthetic valve function. J Am Co11 Cardiol 1983;2:151-73. Brockman S. Mechanism of the movements of atrioventricular valves. Am J Cardiol 1966;17:682-90. Taams M, Gussenhoven E, Cahalan M, Roelandt J, Van Herwerden L, The H, Born N, De Jong N. Transesophageal Doppler color flow imaging in the detection of native and Bj(jrkShiley mitral valve regurgitation. J Am Co11 Cardiol 1989; 13:95-g. Vandenbrink R, Visser C, Basart D, Duren D, De Jong A, Dunning A. Comparison of transthoracic and transesophageal color Doppler flow imaging in patients with mechanical prosthesis in the mitral valve nosition. Am J Cardiol1989;63:147174. Sagar K, Wann S, Paulsen W, Romhilt D. Doppler echocardiographic evaluation of Hancock and Bjsrk Shiley prosthetic valves. J Am Co11 Cardiol 1986;7:681-9. Rashtiaw M, Stevenson D, Allen D. Earl Y, Harrison E, Edmiston A, Faughan P, Rahimtoola &. Flow characteristics of four commonlv used mechanical heart valves. Am J Cardiol 1986;58:743-5i.