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Ultrasonic evaluation of thrombosis of Björk-Shiley aortic valve prosthesis
Ultrasonic evaluation of thrombosis of Bjork-Shiley aortic valve prosthesis Recognition of thrombosis of a Bjork-Shiley aortic valve prosthesis 4 years after insertion in a patient was based upon sudden clinical deterioration, loss of prosthetic sounds, and development of new stenotic and regurgitant murmurs. Thrombotic fixation was confirmed by diagnostic alterations on the echocardiogram. All manifestations reverted to normal after successful surgical debridement of the prosthesis. Echocardiography is a valuable noninvasive adjunct in the differential diagnosis of prosthetic valve malfunction.
Fulvio Orzan, M.D., Efrain Garcia, M.D., Leonard W. Pechacek, Robert J. Hall, M.D., and Denton A. Cooley, M.D., Houston, Texas
Successful detection of malfunction of a prosthetic cardiac valve affected with thrombosis by use of ultrasound has been reported.r" Although cineradiography! and phonocardiography' have been helpful diagnostic aids, echocardiography offers the advantage of a more complete cardiac evaluation and better detection of the cause(s) of dysfunction, as exemplified by the following case.
Case report In 1972, a 38-year-old man underwent replacement of the aortic valve with a No. 23 Bjork-Shiley prosthesis because of severe aortic regurgitation following acute bacterial endocarditis. He was maintained on anticoagulant therapy and remained in excellent health for 4 years. On May 12, 1976, severe dyspnea suddenly developed, and prosthetic valve sounds disappeared. On admission to the hospital, the patient's arterial pressure was 85/65 mm. Hg, and the pulse was regular at a rate of 90 beats per minute. The carotid pulses were of small volume, and a prominent thrill was present. A thrill was also palpated in the upper right parasternal area. The apical impulse was displaced to the sixth left intercostal space at the anterior axillary line. The prosthetic valve "clicks" were absent, and a loud summation gallop was audible. There was a loud basal systolic ejection murmur, an early diastolic blowing murmur in the left parasternal area, and an apical diastolic rumble. The lungs were clear. There were no signs of right-sided heart failure and no petechiae. From the 51. Luke's Episcopal Hospital-Clayton Foundation for Research Laboratory andtheTexas HeartInstitute, Houston, Texas. Received for publication Feb. 7, 1977. Accepted for publication Feb. 25, 1977. Address for reprints: Efrain Garcia, M.D., Texas Heart Institute, P.O. Box 20269, Houston, Texas 77025.
An echocardiogram recorded at the bedside (Fig. I) showed no identifiable echoes from the artificial valve. The aortic root was filled by dense immobile echoes except for a narrow central slit. Obvious diastolic fluttering of the anterior leaflet of the mitral valve was recorded. Left ventricular dimensions and wall motion were normal. The diastolic slope of the pulmonic valve was abnormally flat. A diagnosis was made of immobilization of the aortic prosthetic poppet, in the semiopen position, with both stenosis and regurgitation probably caused by thrombosis. Left ventricular function appeared to be well preserved, and pulmonary hypertension was strongly suspected. 5 Cardiac catheterization was deemed both unnecessary and excessively dangerous, and the patient was subjected to immediate operation. Extensive thrombus was found on both sides of the disc. Thrombectomy was performed without difficulty, and the patient recovered. A postoperative echocardiogram (Fig. 2) clearly showed normal mobility of the prosthetic valve. The fluttering of the mitral leaflet had disappeared, and the diastolic slope of the pulmonic valve was improved.
Discussion Echocardiographic assessment of the Bjork-Shiley cardiac valve prosthesis in the aortic position is difficult. Because of the hinge mechanism, the motion of the disc invariably is oblique to the ultrasonic beam. 6 Nonetheless, the ultrasonic diagnosis of malfunction of this valve is feasible in selected instances, as shown by this case and the experience of others. I, 2 Fluttering of the anterior leaflet of the mitral valve was indicative of regurgitation of the prosthesis. Disappearance of the fluttering after surgical correction in our patient further supports the belief that this observation is pathognomic of aortic insufficiency. Since this sign (to our knowledge) has not been reported to occur
11
I2
The Journal of Thoracic and Cardiovascular Surgery
Orzan et al.
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Fig. 1. Preoperative echocardiogram: A , Aortic root echocardiogram . The aorta (Ao) is filled with dense immobile echoes with a narrow central slit. Left atrial (LA) size is normal. B, Obvious diastolic fluttering of the anterior leaflet of the mitral valve (ALMV). C, Flat diastolic slope (e-f) of the pulmonic valve (PV) echogram .
Fig. 2. Postoperative echocardiogram: A, The disc motion within the aorta (A 0) is clearly visible, seen with sharp opening (0) and closing (c) excursion. Left atrial (LA) size is slightly decreased. B, The fluttering of the anterior leaflet of the mitral valve (ALMV) has disappeared. C, The diastolic slope (ej) of the pulmonic valve (PV) has returned toward normal (20 mm. per second.)
Volume 74 Number 1
Bjork-Shiley aortic valve prosthesis
13
July, 1977
in patients who have prosthetic valve insufficiency, the location of the leak may play a role in its detection. Conceivably, a regurgitant jet directed away from the anterior mitral leaflet may not produce fluttering. The distinction between intra- and periprosthetic leakage is also clinically relevant. Intraprosthetic regurgitation caused by a thrombus is amenable to debridement,? a relatively safe procedure. Conversely, perivalvular dehiscence (particularly when secondary to bacterial endocarditis) can be recurrent and cause a high mortality rate." Periprosthetic insufficiency does not impair the motion of the poppet, whereas thrombosis of the prosthetic valve is easily recognized from the mass of thick linear echoes. This echocardiographic pattern lends strong support to the diagnosis of thrombosis of an aortic prosthesis, a diagnosis which otherwise can be difficult, since a systolic murmur of variable intensity is always present. The echocardiographic detection of stenosis of an artificial valve thus far has been reported only in cases of extreme immobility. 1. 2 The ultrasonic measurement of excursion of the poppet varies according to its orientation within the aorta in relation to the echo beam, and for these reasons recognition of minor degrees of impaired motion is uncertain. Serial echocardiographic examinations of the patient, as well as further exploration of the supraclavicular approach," may shed additional information on delineating the problem of prosthetic aortic valve malfunction.
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3
4
5
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REFERENCES Ben-Zvi, J., Hildner, F. J., Chandraratna, P. A., et aI.: Thrombosis on Bjork-Shiley Aortic Valve Prosthesis: Clinical, Arteriographic, Echocardiographic and Therapeutic Observations in Seven Cases, Am. J. Cardio!. 34: 538, 1974. Srivastava, T. N., Hussain, M., Gray, L. A., et al.: Echocardiographic Diagnosis of a Stuck Bjork-Shiley Aortic Valve Prosthesis, Chest 70: 94, 1976. Brodie, B. R., Grossman, W., McLaurin, L., et al.: Diagnosis of Prosthetic Mitral Valve Malfunction With Combined Echophonocardiography, Circulation 53: 93, 1976. Craige, E., Hutchin, P., and Sutton, R.: Impaired Function of Cloth-Covered Starr-Edwards Mitral Valve Prosthesis: Detection by Phonocardiography, Circulation 41: 141, 1970. Weyman, A. E., Dillon, J. C., Feigenbaum, H., et aI.: Echocardiographic Patterns of Pulmonic Valve Motion With Pulmonary Hypertension, Circulation 50: 905, 1974. Douglas, J. E., and Williams, G. D.: Echocardiographic Evaluation of the Bjork-Shiley Prosthetic Valve, Circulation 50: 52, 1974. Byrd, C. L., Yahr, W. Z., and Greenberg, J. J.: LongTerm Results of "Simple" Thrombectomy for Thrombosed Bjork-Shiley Aortic Valve Prosthesis, Ann. Thorac. Surg. 20: 265, 1975. Slaughter, L., Morris, J. E., and Starr, A.: Prosthetic Valve Endocarditis, Circulation 47: 1319, 1973. Schuchman, H., Feigenbaum, H., Dillon, J. C., et al.: Intracavitary Echoes in Patients With Mitral Prosthetic Valves, J. Clin. Ultrasound 3: 107, 1975.
Fulvio Orzan, M.D., Efrain Garcia, M.D., Leonard W. Pechacek, Robert J. Hall, M.D., and Denton A. Cooley, M.D., Houston, Texas
Successful detection of malfunction of a prosthetic cardiac valve affected with thrombosis by use of ultrasound has been reported.r" Although cineradiography! and phonocardiography' have been helpful diagnostic aids, echocardiography offers the advantage of a more complete cardiac evaluation and better detection of the cause(s) of dysfunction, as exemplified by the following case.
Case report In 1972, a 38-year-old man underwent replacement of the aortic valve with a No. 23 Bjork-Shiley prosthesis because of severe aortic regurgitation following acute bacterial endocarditis. He was maintained on anticoagulant therapy and remained in excellent health for 4 years. On May 12, 1976, severe dyspnea suddenly developed, and prosthetic valve sounds disappeared. On admission to the hospital, the patient's arterial pressure was 85/65 mm. Hg, and the pulse was regular at a rate of 90 beats per minute. The carotid pulses were of small volume, and a prominent thrill was present. A thrill was also palpated in the upper right parasternal area. The apical impulse was displaced to the sixth left intercostal space at the anterior axillary line. The prosthetic valve "clicks" were absent, and a loud summation gallop was audible. There was a loud basal systolic ejection murmur, an early diastolic blowing murmur in the left parasternal area, and an apical diastolic rumble. The lungs were clear. There were no signs of right-sided heart failure and no petechiae. From the 51. Luke's Episcopal Hospital-Clayton Foundation for Research Laboratory andtheTexas HeartInstitute, Houston, Texas. Received for publication Feb. 7, 1977. Accepted for publication Feb. 25, 1977. Address for reprints: Efrain Garcia, M.D., Texas Heart Institute, P.O. Box 20269, Houston, Texas 77025.
An echocardiogram recorded at the bedside (Fig. I) showed no identifiable echoes from the artificial valve. The aortic root was filled by dense immobile echoes except for a narrow central slit. Obvious diastolic fluttering of the anterior leaflet of the mitral valve was recorded. Left ventricular dimensions and wall motion were normal. The diastolic slope of the pulmonic valve was abnormally flat. A diagnosis was made of immobilization of the aortic prosthetic poppet, in the semiopen position, with both stenosis and regurgitation probably caused by thrombosis. Left ventricular function appeared to be well preserved, and pulmonary hypertension was strongly suspected. 5 Cardiac catheterization was deemed both unnecessary and excessively dangerous, and the patient was subjected to immediate operation. Extensive thrombus was found on both sides of the disc. Thrombectomy was performed without difficulty, and the patient recovered. A postoperative echocardiogram (Fig. 2) clearly showed normal mobility of the prosthetic valve. The fluttering of the mitral leaflet had disappeared, and the diastolic slope of the pulmonic valve was improved.
Discussion Echocardiographic assessment of the Bjork-Shiley cardiac valve prosthesis in the aortic position is difficult. Because of the hinge mechanism, the motion of the disc invariably is oblique to the ultrasonic beam. 6 Nonetheless, the ultrasonic diagnosis of malfunction of this valve is feasible in selected instances, as shown by this case and the experience of others. I, 2 Fluttering of the anterior leaflet of the mitral valve was indicative of regurgitation of the prosthesis. Disappearance of the fluttering after surgical correction in our patient further supports the belief that this observation is pathognomic of aortic insufficiency. Since this sign (to our knowledge) has not been reported to occur
11
I2
The Journal of Thoracic and Cardiovascular Surgery
Orzan et al.
mll m llll l l l ll l ll l l l l l l l l l l l l l l l 1I ~1 1 "1 1 1 1 1 1I 1"l l Il l
I
"-- - - ~ -
A
--
---
-
-
=
~
B
Fig. 1. Preoperative echocardiogram: A , Aortic root echocardiogram . The aorta (Ao) is filled with dense immobile echoes with a narrow central slit. Left atrial (LA) size is normal. B, Obvious diastolic fluttering of the anterior leaflet of the mitral valve (ALMV). C, Flat diastolic slope (e-f) of the pulmonic valve (PV) echogram .
Fig. 2. Postoperative echocardiogram: A, The disc motion within the aorta (A 0) is clearly visible, seen with sharp opening (0) and closing (c) excursion. Left atrial (LA) size is slightly decreased. B, The fluttering of the anterior leaflet of the mitral valve (ALMV) has disappeared. C, The diastolic slope (ej) of the pulmonic valve (PV) has returned toward normal (20 mm. per second.)
Volume 74 Number 1
Bjork-Shiley aortic valve prosthesis
13
July, 1977
in patients who have prosthetic valve insufficiency, the location of the leak may play a role in its detection. Conceivably, a regurgitant jet directed away from the anterior mitral leaflet may not produce fluttering. The distinction between intra- and periprosthetic leakage is also clinically relevant. Intraprosthetic regurgitation caused by a thrombus is amenable to debridement,? a relatively safe procedure. Conversely, perivalvular dehiscence (particularly when secondary to bacterial endocarditis) can be recurrent and cause a high mortality rate." Periprosthetic insufficiency does not impair the motion of the poppet, whereas thrombosis of the prosthetic valve is easily recognized from the mass of thick linear echoes. This echocardiographic pattern lends strong support to the diagnosis of thrombosis of an aortic prosthesis, a diagnosis which otherwise can be difficult, since a systolic murmur of variable intensity is always present. The echocardiographic detection of stenosis of an artificial valve thus far has been reported only in cases of extreme immobility. 1. 2 The ultrasonic measurement of excursion of the poppet varies according to its orientation within the aorta in relation to the echo beam, and for these reasons recognition of minor degrees of impaired motion is uncertain. Serial echocardiographic examinations of the patient, as well as further exploration of the supraclavicular approach," may shed additional information on delineating the problem of prosthetic aortic valve malfunction.
2
3
4
5
6
7
8 9
REFERENCES Ben-Zvi, J., Hildner, F. J., Chandraratna, P. A., et aI.: Thrombosis on Bjork-Shiley Aortic Valve Prosthesis: Clinical, Arteriographic, Echocardiographic and Therapeutic Observations in Seven Cases, Am. J. Cardio!. 34: 538, 1974. Srivastava, T. N., Hussain, M., Gray, L. A., et al.: Echocardiographic Diagnosis of a Stuck Bjork-Shiley Aortic Valve Prosthesis, Chest 70: 94, 1976. Brodie, B. R., Grossman, W., McLaurin, L., et al.: Diagnosis of Prosthetic Mitral Valve Malfunction With Combined Echophonocardiography, Circulation 53: 93, 1976. Craige, E., Hutchin, P., and Sutton, R.: Impaired Function of Cloth-Covered Starr-Edwards Mitral Valve Prosthesis: Detection by Phonocardiography, Circulation 41: 141, 1970. Weyman, A. E., Dillon, J. C., Feigenbaum, H., et aI.: Echocardiographic Patterns of Pulmonic Valve Motion With Pulmonary Hypertension, Circulation 50: 905, 1974. Douglas, J. E., and Williams, G. D.: Echocardiographic Evaluation of the Bjork-Shiley Prosthetic Valve, Circulation 50: 52, 1974. Byrd, C. L., Yahr, W. Z., and Greenberg, J. J.: LongTerm Results of "Simple" Thrombectomy for Thrombosed Bjork-Shiley Aortic Valve Prosthesis, Ann. Thorac. Surg. 20: 265, 1975. Slaughter, L., Morris, J. E., and Starr, A.: Prosthetic Valve Endocarditis, Circulation 47: 1319, 1973. Schuchman, H., Feigenbaum, H., Dillon, J. C., et al.: Intracavitary Echoes in Patients With Mitral Prosthetic Valves, J. Clin. Ultrasound 3: 107, 1975.