Prosthetic Heart Valve Obstruction Research Articles

Imaging Spectrum of Valvular and Paravalvular Complications of Prosthetic Heart Valve at CT Angiography.

Prosthetic heart valve (PHV) dysfunction is an uncommon but potentially life-threatening condition. In routine practice, transthoracic echocardiography and cinefluoroscopy comprise first-line imaging for the diagnostic evaluation of PHV dysfunction. In cases in which the findings of echocardiography and cinefluoroscopy remain inconclusive or are contradictory, CT angiography can resolve these conflicts. CT angiography also provides incremental diagnostic information about patients with suspected PHV obstruction and endocarditis, in which case it can demonstrate the anatomic substrate and extent of involvement. Additionally, information regarding the coronary arteries, cardiac dimensions, and retrosternal space may be obtained in cases in which repeat surgery is planned. This imaging essay describes the imaging spectrum of valvular and paravalvular complications of PHV at CT angiography and how the knowledge regarding the spectrum of complications can be incorporated into multimodality imaging for guiding clinical management. Keywords: Prosthetic Heart Valve Dysfunction, Prosthetic Heart Valve Thrombosis, Pannus, Paravalvular Leak, CT Angiography, Cardiac, Valves Supplemental material is available for this article. © RSNA, 2021.

3D Transesophageal Echocardiography (TEE) in assessment of prosthetic heart valve obstruction in comparison of 2D Trans Esophageal echocardiography (TEE)

3D Transesophageal Echocardiography (TEE) in assessment of prosthetic heart valve obstruction in comparison of 2D Trans Esophageal echocardiography (TEE)

439 - Aortic prosthetic heart valve obstruction caused by pannus: characteristics and diagnostic strategy, about a 71 patients multicentric study

439 - Aortic prosthetic heart valve obstruction caused by pannus: characteristics and diagnostic strategy, about a 71 patients multicentric study

Diagnostic evaluation and treatment strategy in patients with suspected prosthetic heart valve dysfunction: The incremental value of MDCT

BackgroundIn patients with suspected prosthetic heart valve (PHV) dysfunction, routine evaluation echocardiography and fluoroscopy may provide unsatisfactory results for identifying the cause of dysfunction. This study assessed the value of MDCT as a routine, complementary imaging modality in suspected PHV-dysfunction for diagnosing the cause of PHV dysfunction and proposing a treatment strategy. MethodsPatients with suspected PHV dysfunction were prospectively recruited. All patients underwent routine diagnostic work-up (TTE, TEE ± fluoroscopy) and additional MDCT imaging. An expert panel reviewed all cases and assessed the diagnosis and treatment strategy, first based on routine evaluation only, second with additional MDCT information. ResultsForty-two patients were included with suspected PHV obstruction (n = 30) and PHV regurgitation (n = 12). The addition of MDCT showed incremental value to routine evaluation in 26/30 (87%) cases for detecting the specific cause of PHV obstruction and in 7/12 (58%) regurgitation cases for assessment of complications and surgical planning. The addition of MDCT resulted in treatment strategy change in 8/30 (27%) patients with suspected obstruction and 3/12 (25%) patients with regurgitation. ConclusionIn addition to echocardiography and fluoroscopy, MDCT may identify the cause of PHV dysfunction and alter the treatment strategy.

Novel imaging strategies for the detection of prosthetic heart valve obstruction and endocarditis.

Prosthetic heart valve (PHV) dysfunction remains difficult to recognise correctly by two-dimensional (2D) transthoracic and transoesophageal echocardiography (TTE/TEE). ECG-triggered multidetector-row computed tomography (MDCT), 18-fluorine-fluorodesoxyglucose positron emission tomography including low-dose CT (FDG-PET) and three-dimensional transoesophageal echocardiography (3D-TEE) may have additional value. This paper reviews the role of these novel imaging tools in the field of PHV obstruction and endocarditis.For acquired PHV obstruction, MDCT is of additional value in mechanical PHVs to differentiate pannus from thrombus as well as to dynamically study leaflet motion and opening/closing angles. For biological PHV obstruction, additional imaging is not beneficial as it does not change patient management. When performed on top of 2D-TTE/TEE, MDCT has additional value for the detection of both vegetations and pseudoaneurysms/abscesses in PHV endocarditis. FDG-PET has no complementary value for the detection of vegetations; however, it appears more sensitive in the early detection of pseudoaneurysms/abscesses. Furthermore, FDG-PET enables the detection of metastatic and primary extra-cardiac infections. Evidence for the additional value of 3D-TEE is scarce.As clinical implications are major, clinicians should have a low threshold to perform additional MDCT in acquired mechanical PHV obstruction. For suspected PHV endocarditis, both FDG-PET and MDCT have complementary value.

経口抗凝固療法に関連する二大合併症（頭蓋内出血，血栓症／血栓弁）の治療，及び併発時の管理

Warfarinによる経口抗凝固薬療法には，効果不足に起因する血栓性合併症と，効果過剰に起因する出血性合併症という双方のリスクが伴う．後者の中で特に重大な合併症である頭蓋内出血の死亡率は50％を超える．予後改善には早急かつ完全なWarfarin拮抗が必須である．新鮮凍結血漿が第一選択だが，Vitamin K依存性凝固因子の含有量が製剤間で異なり必要量が一概に予測できない，拮抗に時間を要する，容量負荷が大きいという側面を有する．緊急時には血液凝固第IX因子複合体が有用だが，適応外使用である．Warfarin拮抗の際には同時に血栓塞栓症の予防も念頭に置かなければならず，特に機械弁挿入患者では完全な止血を確認後，早期からヘパリンを併用し，発症1～2週間でWarfarin再開を考慮する．また機械弁不全をみた場合，血栓溶解療法を行うか否かには血栓弁とパンヌスの鑑別が重要である．さらに頭蓋内出血既往例が血栓弁を生じた場合，血栓溶解療法は禁忌に準じると考えるべきである．

Multimodality Imaging Assessment of Prosthetic Heart Valves.

Echocardiography and fluoroscopy are the main techniques for prosthetic heart valve (PHV) evaluation, but because of specific limitations they may not identify the morphological substrate or the extent of PHV pathology. Cardiac computed tomography (CT) and magnetic resonance imaging (MRI) have emerged as new potential imaging modalities for valve prostheses. We present an overview of the possibilities and pitfalls of CT and MRI for PHV assessment based on a systematic literature review of all experimental and patient studies. For this, a comprehensive systematic search was performed in PubMed and Embase on March 24, 2015, containing CT/MRI and PHV synonyms. Our final selection yielded 82 articles on surgical valves. CT allowed adequate assessment of most modern PHVs and complemented echocardiography in detecting the obstruction cause (pannus or thrombus), bioprosthesis calcifications, and endocarditis extent (valve dehiscence and pseudoaneurysms). No clear advantage over echocardiography was found for the detection of vegetations or periprosthetic regurgitation. Whereas MRI metal artifacts may preclude direct prosthesis analysis, MRI provided information on PHV-related flow patterns and velocities. MRI demonstrated abnormal asymmetrical flow patterns in PHV obstruction and allowed prosthetic regurgitation assessment. Hence, CT shows great clinical relevance as a complementary imaging tool for the diagnostic work-up of patients with suspected PHV obstruction and endocarditis. MRI shows potential for functional PHV assessment although more studies are required to provide diagnostic reference values to allow discrimination of normal from pathological conditions.

An unusual cause of left ventricular outflow tract obstruction: obstructive pannus on the left ventricular side of a mechanical mitral prosthesis.

A 37-year-old female, who had undergone mitral valve replacement with a monoleaflet mechanical prosthesis for mitral stenosis in 1997, was admitted to outpatient clinic with exertional dyspnea and chest discomfort over preceding 3 months. Her physical examination revealed mildly muffled prosthetic valve sounds, pansystolic murmur on lower left sternal border, and bilateral fine rales at the bases of the lungs. Her electrocardiography showed atrial fibrillation. Transthoracic echocardiography revealed severe left ventricular outflow tract (LVOT) obstruction with mean gradient of 42 mmHg (Fig. 1a, c; Video 1) and severe tricuspid regurgitation. Two-dimensional transesophageal echocardiography (2D-TEE) showed stenosis of mechanical mitral valve (MMV) with pressure half-time (PHT) of 157 ms (PHT was 98 ms in the previous echocardiography) and mean gradient of 13 mmHg. Aortic valve function and leaflet motion of MMV were normal, but there was a hyperechogenic appearance at the ventricular side of the MMV. With the transducer array at 120 , 2D-TEE revealed that the hyperechogenic mass on the ventricular side of the MMV caused narrowing of the LVOT (Fig. 2a; Video 2). Real-time three-dimensional transesophageal echocardiography (RT-3D-TEE) clearly delineated an eccentric semicircular pannus overgrowth which was located anteriorly on the ventricular side of the MMV (Fig. 2b; Video 3), resulting in LVOT obstruction (Fig. 2c; Video 4). Redo mitral valve replacement with a bileaflet mechanical prosthesis (no. 29, St. Jude Medical) and concomitant repair of the tricuspid valve were performed, and anteriorly eccentric semicircular pannus tissue was removed from the left ventricular side of the mitral prosthesis (Fig. 2d). Postoperative transthoracic echocardiography (TTE) revealed normal functioning mitral prosthetic valve with normal LVOT gradients (Fig. 1b, d; Video 5). Prosthetic heart valve obstruction caused by pannus formation is an uncommon but serious complication. Determination of the precise etiology of valvular obstruction is essential, as this can have an impact on the course of surgical versus thrombolytic therapy [1]. Although 2DTEE is the first method of choice in the diagnostic algorithm, exact visualization of pannus is almost impossible [2]. However, RT-3D-TEE is a very useful imaging technique and permits differentiation of pannus overgrowth from other MMV pathologies [3, 4]. Herein, we present an anteriorly localized eccentric pannus overgrowth on the left ventricular side of MMV, which is an uncommon cause of LVOT obstruction.

Differentiation of thrombus from pannus as the cause of acquired mechanical prosthetic heart valve obstruction by non-invasive imaging: a review of the literature

For acquired mechanical prosthetic heart valve (PHV) obstruction and suspicion on thrombosis, recently updated European Society of Cardiology guidelines advocate the confirmation of thrombus by transthoracic echocardiography, transesophageal echocardiography (TEE), and fluoroscopy. However, no evidence-based diagnostic algorithm is available for correct thrombus detection, although this is clinically important as fibrinolysis is contraindicated in non-thrombotic obstruction (isolated pannus). Here, we performed a review of the literature in order to propose a diagnostic algorithm. We performed a systematic search in Pubmed and Embase. Included publications were assessed on methodological quality based on the validated Quality Assessment of Diagnostic Accuracy Studies (QUADAS) II checklist. Studies were scarce (n = 15) and the majority were of moderate methodological quality. In total, 238 mechanical PHV's with acquired obstruction and a reliable reference standard were included for the evaluation of the role of fluoroscopy, echocardiography, or multidetector-row computed tomography (MDCT). In acquired PHV obstruction caused by thrombosis, mass detection by TEE and leaflet restriction detected by fluoroscopy were observed in the majority of cases (96 and 100%, respectively). In contrast, in acquired PHV obstruction free of thrombosis (pannus), leaflet restriction detected by fluoroscopy was absent in some cases (17%) and mass detection by TEE was absent in the majority of cases (66%). In case of mass detection by TEE, predictors for obstructive thrombus masses (compared with pannus masses) were leaflet restriction, soft echo density, and increased mass length. In situations of inconclusive echocardiography, MDCT may correctly detect pannus/thrombus based on the morphological aspects and localization. In acquired mechanical PHV obstruction without leaflet restriction and absent mass on TEE, obstructive PHV thrombosis cannot be confirmed and consequently, fibrinolysis is not advised. Based on the literature search and our opinion, a diagnostic algorithm is provided to correctly identify non-thrombotic PHV obstruction, which is highly relevant in daily clinical practice.

Prosthetic heart valve obstruction: thrombolysis or surgical treatment?

Prosthetic valve thrombosis is a potentially life-threatening complication associated with high morbidity and mortality. Transthorasic and transoesophageal echocardiography play an important role to the diagnosis and provides incremental information about the optimal treatment strategy, while fluoroscopy and cardiac computed tomography may be of added value. Guidelines differ on whether surgical treatment or fibrinolysis should be the treatment of choice for the management of left-sided prosthetic valve thrombosis and these uncertainties underline the need for further prospective randomized controlled trials. Thrombus size, New York Heart Association functional class of the patient, the possible contraindications, the availability of each therapeutic option and the clinician's experience are important determinants for the management of prosthetic valve thrombosis.

Surgical Outcome of Prosthetic Heart Valve Obstruction: Single Center Experience

Objective: Valve thrombosis defined as any thrombus not caused by infection attached to or near an operated valve that occludes part of the blood flow path and interferes with valve function. Treatment modalities are thrombolytic therapy, surgical thrombectomy and debridement, or re-replacement. The aim of this study is to review our experience in surgical thrombectomy and debridement for obstructed mechanical valve prosthesis, and the impact of the procedure on the outcome in comparison to re-replacement; Methods: The study was conducted retrospectively between 1995 to 2012 in Department of Cardiothoracic surgery, cardiology and internal medicine, Zagazig University Hospital. 92 patients with stuck valve were divided into two groups. Group (A): 54 patients with re replacement and Group (B): 38 patients treated by thrombectomy and debridement; Results: 92 patients with stuck valves the mean age was 38.4(±9.2), 68 male and 85 female in both groups. The large numbers of cases were mitral valve 35 (64.8%) patients in group A and 22 (57.9%) patients in group B, aortic malfunction in group A was 11 (20.4%)patients and 9 (23.7%) cases in group B, double valve malfunction was rare represent 8 (14.8%) and 7 (18.4%)cases in group A and group B respectively; Conclusion: We conclude that thrombectomy and debridement for malfunctioning mechanical valve is a safe, easy and rapid procedure to perform in some cases to avoid the risk of re replacement.

Diagnosis of the prosthetic heart valve pannus formation with real-time three-dimensional transoesophageal echocardiography

Prosthetic heart valve obstruction (PHVO) caused by pannus formation is an uncommon but serious complication. Although two-dimensional transesophageal echocardiography (2D-TEE) is the method of choice in the evaluation of PHVO, visualization of pannus is almost impossible with 2D-TEE. While demonstrating the precise aetiology of PHVO is essential for guiding the therapy, either thrombolysis for valve thrombosis or surgery for pannus formation, more sophisticated imaging techniques are needed in patients with suspected pannus formation. We present real-time 3D-TEE imaging in a patient with mechanical mitral PHVO, clearly demonstrating pannus overgrowth.

Comparison of Multidetector-Row Computed Tomography to Echocardiography and Fluoroscopy for Evaluation of Patients With Mechanical Prosthetic Valve Obstruction

For evaluation of prosthetic heart valve obstruction echocardiography and fluoroscopy provide primarily functional information but may not unequivocally establish the cause of dysfunction. Our objective was to evaluate whether multidetector-row computed tomographic (MDCT) imaging could detect the morphologic substrate for such functional abnormalities. Thirteen patients with 15 prosthetic valves, in whom prosthetic valve obstruction was suspected from echocardiography or fluoroscopy but no sufficient cause could be found, underwent electrocardiographically gated multidetector-row computed tomography. MDCT data were retrospectively reconstructed at every 10% of the electrocardiographic interval and analyzed using multiplanar reformatting in anatomically adapted planes. MDCT images were evaluated for morphologic prosthetic and periprosthetic abnormalities. Results could be compared to intraoperative findings or autopsy in 7 patients. Multidetector-row computed tomography disclosed a morphologic substrate for obstruction in 8 of 13 patients. MDCT findings compatible with obstruction were confirmed at surgery or autopsy in 6 patients. In a seventh patient, incomplete leaflet closure found with multidetector-row computed tomography was confirmed at surgery. The most commonly identified causes for obstruction were subprosthetic tissue (6 patients) and abnormal anatomic orientation (3 patients). Despite an indication for surgery, 2 patients were not operated on due to recurrent bacteremias and prohibitive co-morbidity. Multidetector-row computed tomography detected leaflet motion restriction in 7 patients compared to 4 by fluoroscopy. Confirmation of leaflet restriction was available in 5 patients. Multidetector-row computed tomography missed a periprosthetic leak. In conclusion, this initial experience demonstrates that multidetector-row computed tomography can identify causes of prosthetic valve obstruction that constitute indications for surgery but are missed at echocardiography or fluoroscopy.

Recurrent Pulmonary Edema in a Patient With a Prosthetic Mitral Valve

Prosthetic heart valve obstruction is a severe and potentially fatal complication. We present a patient with a Bjork-Shiley prosthetic mitral and aortic valve implantation and recurrent pulmonary edema. Echocardiogram showed a rate-dependent "obstruction alternans" of the prosthetic mitral valve due to pannus formation.

Management of prosthetic heart valve obstruction: Speech for the surgery?

Management of prosthetic heart valve obstruction: Speech for the surgery?

Abstract 6108: Cardiac 64-slice Multidetector Computerized Tomography in the Management of Prosthetic Heart Valve Obstruction

Differentiation of pannus (P) and thrombus (THR) in prosthetic heart valve obstruction (PHVO) is still a confusive state at the present cardiological practise. Transesophageal echocardiography (TEE) is not fully capable method in this condition. We considered that cardiac 64-slice multidetector computerized tomography (MDCT) may have a value in the management of PHVO. Thirtytwo of 37 pts (22 male, mean age 47±11 years, 17 with atrial fibrillation) with PHVO (35 mitral, 2 tricuspid) were detected with TEE and also with MDCT before and after thrombolytic therapy (TT). Five pts having monoleaflet valves were excluded due to excessive artifacts. Pre-TT MDCT revealed at least 1 culprit mass (CM) which was considered to be the cause of PHVO and the Hounsfield unit (HU) values of CM’s were measured. All pts underwent TT under the guidance of serial TEE. The study consisted of 2 groups up to response of CM’s to TT demonstrated by post-TT MDCT. Group I: Successfully lysed CM’s, Group II: Nonresponder CM’s. TEE disclosed THR in 26 pts, however the cause of PHVO in 6 pts remained undefined. Pre-TT MDCT disclosed 45 distinct CM’s on 32 valves. Post-TT MDCT disclosed the number of CM’s for groups I and II: 26 and 19, respectively. Significant difference between mean HU values of groups was found [87 (range 11–180), 331 (range 168–510), respectively, p<0.001]. A cut-off value of HU>200 predicted nonresponder CM’s (sensitivity 94%, specificity 96%, p<0.001). CM’s of 6 pts with undefined TEE findings were all in group II and pure P was demonstrated surgically. In group I, 17 of 26 (%65) CM’s were completely and the remaining partially lysed which was confirmed by TEE. A cut-off value of HU<100 predicted complete lysis (sensitivity 100%, specificity %95, p<0.001). Subgroup analysis of CM’s with HU=100–200 revealed 10% completely and 80% partially lysis and 10% remained unresponded as confirmed by TEE. MDCT can be a useful technique for evaluation of PHVO caused by THR or P formation. Higher HU values denote P whereas the lower values THR. MDCT can also predict the response to TT. The higher the HU value the less the successful outcome. The CM’s with HU>200 are almost always resistant to TT.

Thrombectomy for Prosthetic Heart Valve Obstruction

Journal of Cardiac SurgeryVolume 22, Issue 3 p. 218-218 Thrombectomy for Prosthetic Heart Valve Obstruction P. Ogutu, P. Ogutu Division of Cardiothoracic Surgery, Kerckhoff-Clinic Foundation, Benekestr, 2-8, 61231 Bad Nauheim, GermanySearch for more papers by this authorZ. Szalay, Z. Szalay Division of Cardiothoracic Surgery, Kerckhoff-Clinic Foundation, Benekestr, 2-8, 61231 Bad Nauheim, GermanySearch for more papers by this authorM. Roth, M. Roth Division of Cardiothoracic Surgery, Kerckhoff-Clinic Foundation, Benekestr, 2-8, 61231 Bad Nauheim, GermanySearch for more papers by this authorM. Schönburg, M. Schönburg Division of Cardiothoracic Surgery, Kerckhoff-Clinic Foundation, Benekestr, 2-8, 61231 Bad Nauheim, GermanySearch for more papers by this authorB. Kraus, B. Kraus Division of Anaesthesiology, Kerckhoff-Clinic Foundation, Benekestr, 2-8, 61231 Bad Nauheim, GermanySearch for more papers by this authorW.-P. Klövekorn, W.-P. Klövekorn Division of Cardiothoracic Surgery, Kerckhoff-Clinic Foundation, Benekestr, 2-8, 61231 Bad Nauheim, GermanySearch for more papers by this author P. Ogutu, P. Ogutu Division of Cardiothoracic Surgery, Kerckhoff-Clinic Foundation, Benekestr, 2-8, 61231 Bad Nauheim, GermanySearch for more papers by this authorZ. Szalay, Z. Szalay Division of Cardiothoracic Surgery, Kerckhoff-Clinic Foundation, Benekestr, 2-8, 61231 Bad Nauheim, GermanySearch for more papers by this authorM. Roth, M. Roth Division of Cardiothoracic Surgery, Kerckhoff-Clinic Foundation, Benekestr, 2-8, 61231 Bad Nauheim, GermanySearch for more papers by this authorM. Schönburg, M. Schönburg Division of Cardiothoracic Surgery, Kerckhoff-Clinic Foundation, Benekestr, 2-8, 61231 Bad Nauheim, GermanySearch for more papers by this authorB. Kraus, B. Kraus Division of Anaesthesiology, Kerckhoff-Clinic Foundation, Benekestr, 2-8, 61231 Bad Nauheim, GermanySearch for more papers by this authorW.-P. Klövekorn, W.-P. Klövekorn Division of Cardiothoracic Surgery, Kerckhoff-Clinic Foundation, Benekestr, 2-8, 61231 Bad Nauheim, GermanySearch for more papers by this author First published: 27 March 2007 https://doi.org/10.1111/j.1540-8191.2007.00389.x Address for correspondence: P. Ogutu, Division of Cardiothoracic Surgery, Kerckhoff-Clinic Foundation, Benekestr, 2-8, 61231 Bad Nauheim, Germany. e-mail: [email protected] Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume22, Issue3May/June 2007Pages 218-218 RelatedInformation

Surgery for prosthetic valve obstruction. A single center study of 136 patients.

Prosthetic heart valve obstruction (PHVO) is a potentially fatal complication of heart valve replacement with mechanical substitute mainly due to thrombosis. The purpose of this report is to present a single-center experience of 136 consecutive patients operated on between 1978 and 2001. The diagnosis of PHVO was mainly assessed by fluoroscopy and/or echocardiography. Thrombosed valves were bileaflet (82), tilting disc (47) and ball cage (7) valves; of these, 90 were in mitral, 38 in aortic, six in aortic and mitral position, and two in tricuspid position. The mean interval between the first implantation and valve thrombosis was 7.4+/-6.6 years (range 1 day to 28 years); in 37 patients preoperative medical therapy (fibrinolysis in 21, and heparin alone in 16) was unsuccessful. Operative procedures included valve re-replacement in 104 cases and declotting-pannus excision in 32 cases. Early hospital mortality was 10.3% (14 patients), all in NYHA class III or IV, and one patient suffered a perioperative cerebral embolic event. Surgery was then successful in 121 of 136 patients (89%), but during a 3.15-year follow-up, prosthetic heart valve thrombosis recurred in ten out of 122 survivors (8.1%). From this experience, it can be concluded that for most PHVO, early operation is currently effective and safe, especially in patients in stable hemodynamic condition preoperatively.