A rare case of obstruction of the artificial aortic valve with pannus formation

    Authors

    Abstract

    **Introduction:** Aortic stenosis is the most common valvular heart disease. Its prevalence increases with age and while it occurs rather rarely in people in their fifties (0.2%), it is quite an often comorbidity in octogenerians (9.8%). Symptomatic patients with aortic stenosis exhibit as low survival rates, as 20% within 5 years of symptom onset. Over 67000 aortic valve replacement procedures are performed yearly in the USA, i.e. 112 in 100 thousand people. Prosthetic valve obstruction occurs in 0.4-6.0% of patients after AVR, mostly due to valve thrombosis (75%). However, in 10% of patients with prosthetic valve obstruction, it is a result of pannus formation (mostly on the ventricular side of the valve). (1, 2) **Case report:** A 71-year-old female patient who underwent artificial aortic valve replacement in 2005, was admitted to Clinical Hospital due to signs of congestive heart failure and progressive dyspnea. Transthoracic echocardiography showed severe stenosis of the artificial valve (mean PG 46 mmHg, max PG 73 mmHg, AVA 0.5 cm2, Vmax 4.3 m/s), left ventricular hypertrophy, preserved left ventricular systolic function (EF 65%), and an enlarged left atrium (5.4 cm). Mitral valve was sclerotic and calcified, with reduced mobility of the posterior cusp and signs of moderate mitral stenosis (MVA 1.7 cm2, PHT 117 ms, max PG 15 mmHg, mean PG 7 mmHg) and moderate mitral regurgitation jet (VC 5mm, Vmax 6.2 m/s). Transesophageal echocardiography (TEE) confirmed severe aortic stenosis, moderate mitral regurgitation (VC 6 mm) and moderate mitral stenosis (Vmax 2.5 m/s, max PG 25 mmHg, mean PG 10 mmHg) due to immobile P1, P2 and P3 segments of the posterior cusp. Coronary angiography showed a normal angiogram. Fluoroscopy revealed only one functional artificial aortic valve cusp. Invasive hemodynamic measurements showed a significant pulmonary artery hypertension (49 mmHg), with only slightly elevated both ventricle filling pressures (RAP 10 mmHg, PCWP 18 mmHg). Cardiac index was normal (2.7 L/min/m2), as was the pulmonary vascular resistance (2.3 WU). Patient underwent surgical repair of aortic valve prosthesis – pannus debridement and artificial mitral valve replacement. Postoperative TEE showed normal functioning aortic and mitral valves. **Conclusion:** Pannus induced artificial valve obstruction is a rare postoperative complication, that we have to bear in mind when treating patients after aortic valve replacement.

    Keywords

    aortic stenosis, surgical aortic valve replacement, postoperative aortic vavle complications

    DOI

    https://doi.org/10.15836/ccar2016.625

    Literature

    1. Soumoulou JB, Cianciulli TF, Zappi A, Cozzarin A, Saccheri MC, Lax JA, et al. Limitations of multimodality imaging in the diagnosis of pannus formation in prosthetic aortic valve and review of the literature. World J Cardiol. 2015;7(4):224–9. https://doi.org/10.4330/wjc.v7.i4.224
    2. Salamon J, Munoz-Mendoza J, Liebelt JJ, Taub CC. Mechanical valve obstruction: Review of diagnostic and treatment strategies. World J Cardiol. 2015;7(12):875–81. https://doi.org/10.4330/wjc.v7.i12.875
    Cardiologia Croatica
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    A rare case of obstruction of the artificial aortic valve with pannus formation

    Extended Abstract
    Issue12
    Published
    Pages625
    PDF via DOIhttps://doi.org/10.15836/ccar2016.625
    aortic stenosis
    surgical aortic valve replacement
    postoperative aortic vavle complications

    Authors

    Vera Slatinski*ORCIDUniversity Hospital “Sveti Duh”, Zagreb, Croatia
    Dario GulinORCIDUniversity Hospital “Sveti Duh”, Zagreb, Croatia
    Ante PašalićORCIDUniversity Hospital “Sveti Duh”, Zagreb, Croatia
    Jozica ŠikićORCIDUniversity Hospital “Sveti Duh”, Zagreb, Croatia

    Abstract

    **Introduction:** Aortic stenosis is the most common valvular heart disease. Its prevalence increases with age and while it occurs rather rarely in people in their fifties (0.2%), it is quite an often comorbidity in octogenerians (9.8%). Symptomatic patients with aortic stenosis exhibit as low survival rates, as 20% within 5 years of symptom onset. Over 67000 aortic valve replacement procedures are performed yearly in the USA, i.e. 112 in 100 thousand people. Prosthetic valve obstruction occurs in 0.4-6.0% of patients after AVR, mostly due to valve thrombosis (75%). However, in 10% of patients with prosthetic valve obstruction, it is a result of pannus formation (mostly on the ventricular side of the valve). (1, 2) **Case report:** A 71-year-old female patient who underwent artificial aortic valve replacement in 2005, was admitted to Clinical Hospital due to signs of congestive heart failure and progressive dyspnea. Transthoracic echocardiography showed severe stenosis of the artificial valve (mean PG 46 mmHg, max PG 73 mmHg, AVA 0.5 cm2, Vmax 4.3 m/s), left ventricular hypertrophy, preserved left ventricular systolic function (EF 65%), and an enlarged left atrium (5.4 cm). Mitral valve was sclerotic and calcified, with reduced mobility of the posterior cusp and signs of moderate mitral stenosis (MVA 1.7 cm2, PHT 117 ms, max PG 15 mmHg, mean PG 7 mmHg) and moderate mitral regurgitation jet (VC 5mm, Vmax 6.2 m/s). Transesophageal echocardiography (TEE) confirmed severe aortic stenosis, moderate mitral regurgitation (VC 6 mm) and moderate mitral stenosis (Vmax 2.5 m/s, max PG 25 mmHg, mean PG 10 mmHg) due to immobile P1, P2 and P3 segments of the posterior cusp. Coronary angiography showed a normal angiogram. Fluoroscopy revealed only one functional artificial aortic valve cusp. Invasive hemodynamic measurements showed a significant pulmonary artery hypertension (49 mmHg), with only slightly elevated both ventricle filling pressures (RAP 10 mmHg, PCWP 18 mmHg). Cardiac index was normal (2.7 L/min/m2), as was the pulmonary vascular resistance (2.3 WU). Patient underwent surgical repair of aortic valve prosthesis – pannus debridement and artificial mitral valve replacement. Postoperative TEE showed normal functioning aortic and mitral valves. **Conclusion:** Pannus induced artificial valve obstruction is a rare postoperative complication, that we have to bear in mind when treating patients after aortic valve replacement.

    Literature

    1. 1.
      Soumoulou JB, Cianciulli TF, Zappi A, Cozzarin A, Saccheri MC, Lax JA, et al. Limitations of multimodality imaging in the diagnosis of pannus formation in prosthetic aortic valve and review of the literature. World J Cardiol. 2015;7(4):224–9.DOI
    2. 2.
      Salamon J, Munoz-Mendoza J, Liebelt JJ, Taub CC. Mechanical valve obstruction: Review of diagnostic and treatment strategies. World J Cardiol. 2015;7(12):875–81.DOI