A heart coping with a dysfunctional prosthetic valve (at least once in every few beats…) http://www.escardio.org/communities/Working-Groups/valvular/Pages/welcome.aspx

1. A heart coping with a
dysfunctional prosthetic
valve (at least once in
every few beats…)
Dr Taylan Akgun
Kartal Kosuyolu Heart and Research
Hospital, Istanbul, Turkey
Dr Cemil Izgi
Royal Brompton Hospital
London, UK

2. Clinical presentation
• 45 years old, Female
• Presented with severe dyspnea (NYHA Class III)
• Mechanical mitral prosthetic valve
-implanted 10 years ago
-mono-leaflet tilting disc
-optimum INR (3.5 at presentation)
• Progressively increasing shortness of breath for the last two
months
• Normal sinus rhythm

3. Physical examination
• Mechanical prosthetic valve sounds
- decreased intensity, increasing every two/three heart beats
• BP 130/90 mm Hg
- dropping intermittently to 80/60 mm Hg, as seen in the arterial line
- pulsus alternans
• Bilateral rales up to mid zones
• Pretibial edema

4. Echocardiography
•Transthoracic echocardiography
-increased transvalvular gradient (mean Grad. 17 mmHg)
-impaired valve opening (but difficult to fully assess)
 Findings highly suggestive of prosthetic valve dysfunction
•Transesophageal echocardiography
-Limited monoleaflet motion
-opening intermittently only in every two or three beats
-No obvious thrombus seen

5. Transesophageal echocardiography
Watch video
intermittent leaflet opening once in
every two or three beats; only
when the left atrial pressure
increases in consecutive cycles
high enough to overcome the
obstruction
Doppler tracing of
transmitral flow with the
ECG tracing. Mitral flow
occurs only once in two
or three beats.

6. Diagnosis
• Severe prosthetic valve dysfunction with limited leaflet opening.
-Pannus or Thrombus?
• Factors suggesting pannus rather than thrombus1,2
 No obvious obstructive thrombus but instead an echo dense, immobile
structure observed on transesophageal echo
 Optimum INR
 No recent history of systemic embolism
 Subacute development
Findings were suggestive of pannus and the patient was referred for emergent
surgery.
D. Hering, C. Piper and D. Horstkotte. Management of prosthetic valve thrombosis. European Heart
Journal Supplements (2001) 3 (Supplement Q), Q22–Q26.
1

7. Surgery
• Pannus extending to the valve leaflet and obstructing its opening
Valve was excised and a new bileaflet mechanical prosthetic valve was implanted.

8. Pannus
•
Pannus is a fibroeleastic tissue ingrowth from the valve annulus. Mostly starts
from the surgical line in the annulus and is circular in the plane of the valve.
Pannus formation is mostly unpredictable and there is no established risk factor
for its formation.
•
In a large series prosthetic valve obstruction, rate of reoperation for pannus was
0.24%/patient per year and for valvular thrombosis was 0.15%/patient per
year.*
•
Differentiation of pannus and thrombus is important as thrombolysis may be a
treatment option for prosthetic heart valve thrombosis but obviously will not be
effective for pannus which should be managed surgically.
•
In any case of suspected mechanical prosthetic valve obstructive dysfunction
fluoroscopy, transesophageal echo and multislice CT provide clues on the cause
of obstruction.
*Rizzoli G, e al. Reoperations for acute prosthetic thrombosis and pannus: an assessment of rates,
relationship and risk. Eur J Cardiothorac Surg. 1999 Jul;16(1):74-80.

9. Obstructive prosthetic heart valve dysfunction*
Thrombus
Pannus
Patient Prosthesis
mismatch
Clinical presentation
Acute
Low INR
Generally non acute
Adequate INR
Non-acute
Adequate INR
Fluoroscopy
Restriction of leaflet
opening
Restriction of leaflet opening
(maybe absent )
No restriction of leaflet
opening
Echocardiography
(TTE, TEE)
Increased gradient
Mass on the valve; large
and soft echodensity
Increased gradient
No mass identified on the
valve or if present small,
circular and high echogenity
Increased gradient (also
increased in the baseline
echo and no recent increase)
No mass on the valve
CT
Restriction of leaflet
opening
Mass on the valve
Restriction of leaflet opening
(maybe absent )
Small circular mass along the
valve plane
No restriction of leaflet
opening
No mass on the valve
*Table modified from Tanis W et al. Differentiation of thrombus from pannus as the cause of acquired
mechanical prosthetic heart valve obstruction by non-invasive imaging: a review of the literature. Eur Heart J
Cardiovasc Imaging. 2013 Aug 2. doi:10.1093/ehjci/jet127 [Epub ahead of print]

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