Recurrent pannus formation causing prosthetic aortic valve dysfunction: is excision without valve re-replacement applicable?

Pannus-related left main trunk ostial stenosis after aortic valve replacement

A 34-year-old woman was hospitalized with shortness of breath and chest tightness and pain. She had undergone aortic valve replacement for aortic stenosis at the age of 18 years. Transthoracic echocardiography showed left ventricular asynergy and a high aortic valve pressure gradient. Thus, structural valve deterioration was diagnosed. Coronary computed tomography and coronary angiography revealed left main trunk ostial stenosis that had caused acute anteroseptal myocardial infarction. Urgent surgery revealed pannus formation around the prosthetic valve and covering the ostium of the left main trunk. A Bentall procedure and coronary artery bypass grafting were performed. The postoperative course was uneventful.

Hemodynamic Performance of Dysfunctional Prosthetic Heart Valve with the Concomitant Presence of Subaortic Stenosis: In Silico Study

The prosthetic heart valve is vulnerable to dysfunction after surgery, thus a frequent assessment is required. Doppler electrocardiography and its quantitative parameters are commonly used to assess the performance of the prosthetic heart valves and provide detailed information on the interaction between the heart chambers and related prosthetic valves, allowing early detection of complications. However, in the case of the presence of subaortic stenosis, the accuracy of Doppler has not been fully investigated in previous studies and guidelines. Therefore, it is important to evaluate the accuracy of the parameters in such cases to get early detection, and a proper treatment plan for the patient, at the right time. In the current study, a CFD simulation was performed for the blood flow through a Bileaflet Mechanical Heart Valve (BMHV) with concomitant obstruction in the Left Ventricle Outflow Tract (LVOT). The current study explores the impact of the presence of the subaortic on flow patterns. It also investigates the accuracy of (BMHV) evaluation using Doppler parameters, as proposed in the American Society of Echocardiography (ASE) guidelines.

Imaging of the aortic root on high-pitch non-gated and ECG-gated CT: awareness is the key!

The aortic pathologies are well recognized on imaging. However, conventionally cardiac and proximal aortic abnormalities were only seen on dedicated cardiac or aortic studies due to need for ECG gating. Advances in CT technology have allowed motionless imaging of the chest and abdomen, leading to an increased visualization of cardiac and aortic root diseases on non-ECG-gated imaging. The advances are mostly driven by high pitch due to faster gantry rotation and table speed. The high-pitch scans are being increasingly used for variety of clinical indications because the images are free of motion artifact (both breathing and pulsation) as well as decreased radiation dose. Recognition of aortic root pathologies may be challenging due to lack of familiarity of radiologists with disease spectrum and their imaging appearance. It is important to recognize some of these conditions as early diagnosis and intervention is key to improving prognosis. We present a comprehensive review of proximal aortic anatomy, pathologies commonly seen at the aortic root, and their imaging appearances to familiarize radiologists with the diseases of this location.

Early clinical outcomes of simple pannus removal for mechanical aortic valve stenosis

BACKGROUND

This study aimed to confirm the safety and feasibility of simple pannus removal in patients with mechanical aortic valve dysfunction for pannus overgrowth by evaluating its early clinical outcomes.

METHODS

From March 2015 to April 2019, 24 consecutive patients with mechanical aortic valve dysfunction due to subaortic pannus underwent reoperation. In 12 patients the repeat aortic valve replacement (AVR) was performed, and 12 received the simple pannus removal to preserve the previously implanted prosthesis.

RESULTS

There was only 1 in-hospital death in simple pannus removal group. Significant differences were obtained between procedures in cardiopulmonary bypass (CPB) and aortic cross-clamp time (128.7 vs 179.7 and 74.2 vs 132.7 mins, respectively, P < 0.05). The C-reactive protein (CRP) in simple pannus removal group was lower on the first day (0.13 ± 0.09 vs 0.31 ± 0.22 mg/dl, P < 0.05) and continued to be lower within 1 week after operation. There was no significant difference between procedures in aortic transvalvular peak velocity and transvalvular mean pressure gradient (TMPG) (2.6 ± 0.4 vs 2.5 ± 0.4 m/s and 13.2 ± 3.6 vs 11.6 ± 2.6 mmHg, respectively, P > 0.05) in echocardiography 1 week after operation. In addition, the aortic transvalvular peak velocity and TMPG in echocardiography 1 week after operation in pannus removal group between the repeat and initial surgery were not statistically significant (2.6 ± 0.4 vs. 2.5 ± 0.3 m/s, 13.2 ± 3.6 vs. 13.0 ± 3.5 mmHg, P > 0.05).

CONCLUSIONS

Simple pannus removal was a safe and effective procedure with satisfied early clinical outcomes for pannus overgrowth in mechanical aortic valve. However, further randomized and long-term follow-up studies were warranted to determine the clinical effects of the simple aortic pannus removal.

Aorta-atria-septum combined incision for aortic valve re-replacement

This case report illustrates a patient who underwent supra-annular mechanical aortic valve replacement then suffered from prosthesis dysfunction, increasing pressure gradient with aortic valve. She was successfully underwent aortic valve re-replacement, sub-annular pannus removing and aortic annulus enlargement procedures through combined cardiac incision passing through aortic root, right atrium (RA), and upper atrial septum. This incision provides optimal visual operative field and simplifies dissection.

Dysfunction of mechanical heart valve prosthesis: experience with surgical management in 48 patients

BACKGROUND

Dysfunction of mechanical heart valve prostheses is an unusual but potentially lethal complication after mechanical prosthetic valve replacement. We seek to report our experience with mechanical valve dysfunction regarding etiology, surgical techniques and early outcomes.

METHODS

Clinical data of 48 patients with mechanical valve dysfunction surgically treated between October 1996 and June 2011 were analyzed.

RESULTS

Mean age was 43.7±10.9 years and 34 were female (70.8%). The median interval from primary valve implantation to dysfunction was 44.5 months (range, 1 hour to 20 years). There were 21 emergent and 27 elective reoperations. The etiology was thrombosis in 19 cases (39.6%), pannus in 12 (25%), thrombosis and pannus in 11 (22.9%), improper disc orientation in 2 (4.1%), missing leaflet in 1 (2.1%), excessively long knot end in 1 (2.1%), endogenous factor in 1 (2.1%) and unidentified in 1 (2.1%). Surgical procedure was mechanical valve replacement in 37 cases (77.1%), bioprosthetic valve replacement in 7 (14.9%), disc rotation in 2 (4.2%) and excision of excessive knot end in 1 (2.1%). Early deaths occurred in 7 patients (14.6%), due to low cardiac output in 3 (6.3%), multi-organ failure in 2 (4.2%) and refractory ventricular fibrillation in 2 (4.2%). Complications occurred in 10 patients (20.8%).

CONCLUSIONS

Surgical management of mechanical valve dysfunction is associated with significant mortality and morbidity. Earlier identification and prompt reoperation are vital to achieving better clinical outcomes. The high incidence of thrombosis in this series highlights the need for adequate anticoagulation and regular follow-up after mechanical valve replacement.

Pannus-related prosthetic valve dysfunction. Case report

Pannus-related prosthetic valve dysfunction, a complication of mechanical prosthetic valve replacement, is rare, with a slowly progressive evolution, but it can be acute, severe, requiring surgical reintervention. We present the case of a patient with a mechanical single disc aortic prosthesis, with moderate prosthesis-patient mismatch, minor pannus found on previous ultrasound examinations, who presented to our service with angina pain with a duration of 1 hour, subsequently interpreted as non-ST segment elevation myocardial infarction (NSTEMI) syndrome. Coronarography showed normal epicardial coronary arteries, an ample movement of the prosthetic disc, without evidence of coronary thromboembolism, and Gated Single-Photon Emission Computerized Tomography (SPECT) with Technetium (Tc)-99m detected no perfusion defects. Transthoracic echocardiography (TTE) evidenced a dysfunctional prosthesis due to a subvalvular mass; transesophageal echocardiography (TOE) showed the interference of this mass, with a pannus appearance, with the closure of the prosthetic disc. Under conditions of repeated angina episodes, under anticoagulant treatment, surgery was performed, with the intraoperative confirmation of pannus and its removal. Postoperative evolution was favorable. This case reflects the diagnostic and therapeutic management problems of pannus-related prosthetic valve dysfunction.

Anesthetic management of a patient with obstructive prosthetic aortic valve dysfunction: a case report

We present a 55-year-old female patient who underwent burr-hole drainage due to chronic subdural hematoma, with obstructive prosthetic aortic valve dysfunction. Anesthetic management of a patient with severe obstructive prosthetic aortic valve dysfunction can be challenging. Similar considerations should be given to patients with aortic stenosis with an additional emphasis on thrombotic complication due to discontinuation of anticoagulation, which may further jeopardize the valve dysfunction. This case emphasizes the importance of a comprehensive understanding of the etiology and hemodynamic consequences of obstructive prosthetic valve dysfunction and the adequacy of anticoagulation for patients undergoing noncardiac surgery even after a successful valve replacement.

[A rare case of two mechanisms of prosthetic valve dysfunction in the same patient]

Prosthetic valve dysfunction is a significant clinical event. Determining its etiological mechanism and severity can be difficult. The authors present the case of a 50-year-old man, with two mechanical valve prostheses in aortic and mitral positions, hospitalized for decompensated heart failure. He had a long history of rheumatic multivalvular disease and had undergone three heart surgeries. On admission, investigation led to a diagnosis of severe dysfunction of both mechanical prostheses with different etiologies and mechanisms: pannus formation in the prosthetic aortic valve and intermittent dysfunction of the mitral prosthesis due to interference of a ruptured chorda tendinea in closure of the disks. The patient was reoperated, leading to significant improvement in functional class.