https://orcid.org/0000-0002-6319-4119
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Giovanni Teruzzi, Daniela Trabattoni, Gianluca Polvani, Manuela Muratori, Piero Montorsi, An unusual mechanical aortic prosthetic valve dysfunction: role of a diagnostic multimodality imaging protocol, European Heart Journal - Cardiovascular Imaging, Volume 21, Issue 9, September 2020, Page 1021, https://doi.org/10.1093/ehjci/jeaa086
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A 73-year-old woman was admitted to our hospital because of fever, cough, and respiratory distress in the last week. She had undergone aortic valve replacement for aortic stenosis with a 21 ∅ Sorin Bicarbon bileaflet prosthesis in 2007. Follow-up was uneventful. On admission, the electrocardiogram was unremarkable. A chest X-ray showed middle right lung lobe pneumonia. Transthoracic echocardiogram (poor acoustic window) showed a significant aortic regurgitation (previously not reported) with a normally contracting, not dilated left ventricle. The blood pressure (radial artery) monitoring showed a cyclic change of the aortic waveform from a normal morphology to one suggestive of aortic regurgitation, with a 2:8 ratio (Panel A). As per guidelines, cinefluoroscopy was performed confirming the blood pressure changes as a sequence of two normal leaflet opening/closing sequence interspersed with 10 opening only cycles (Supplementary data online, Video S1). When closed, one leaflet did not fully reach the internal ridge (arrow) suggesting a hinge mechanism malfunction (Panel B). Due to the poor patient respiratory conditions and the suboptimal TEE reliability to differentiate pannus and thrombus in aortic prosthesis a thoracic computed tomography angiography was performed showing hypodense sub-prosthetic tissue only on the ventricular side curved along the prosthesis ring as potential pannus formation (Panel C). The coexistence of thrombus could not be excluded. According to these results, surgical re-intervention was preferred over thrombolysis. Intra-operative TEE confirmed severe aortic insufficiency (Panel D, Supplementary data online, Video S2). A wide sub-valvular pannus formation (with minor thrombotic material) was found and excised (Panels E and F). A biological aortic prosthesis was positioned with complete patient recovery.
