Prosthetic Valve Malfunction Research Articles

Malposition of Central Venous Pressure Catheter as a Rare Cause of Tricuspid Valve Prosthesis Malfunction: A Case Report

Prosthetic valve malfunction is a hazardous clinical entity that needs early diagnosis and management. Hereby, we present a case of tricuspid valve (TV) malfunction due to interaction of central venous pressure (CVP) catheter with TV leaflets. Our case was a 38-year-old male who referred to our center with the diagnosis of TV malfunction. Confirming the diagnosis of TV malfunction, intravenous Heparin was initiated. Anticoagulation therapy was discontinued early due to the development of significant headache in the setting of subarachnoid hemorrhage. Due to contraindication of anticoagulation therapy, he underwent redo TV. On the 4th post-operative day, echocardiography examination illustrated significant increase in gradients of TV prosthesis. At this time, fluoroscopy depicted interaction of CVP catheter with TV leaflets due to its cardiac advancement resulted in fixed TV leaflets in semi-open position. By extraction of CVP catheter the TV gradients improved immediately. Malposition of CVP catheter or large CVP catheter could be considered as one of the rare causes of TV malfunction. Repositioning of CVP catheter brings dramatic improvement in this case.

Diagnostic Value of D-Dimer and INR in Patients Suspected to Have Prosthetic Valve Dysfunction.

Prosthetic valve dysfunction is a potentially critical complication of heart valve replacement. An easy and quickly applicable diagnostic procedure is required for recognizing the prosthetic valve dysfunction. The purpose of this study was to prospectively define the diagnostic value of D-dimer and INR level in predicting prosthetic valve dysfunction. This cross-sectional study was performed in 70 patients suspected to have prosthetic valve dysfunction admitted to Imam Ali Hospital, affiliated with Kermanshah University of Medical Sciences (KUMS), Kermanshah Province, Iran. Cinefluoroscopy, as the gold standard diagnostic test, was used for the diagnosis of prosthetic valve dysfunction in enrolled patients. Two milliliters of blood from each patient were taken into a tube containing sodium citrate anticoagulant. To evaluate D-dimer, the cutoff value was set at 500 ng/ml. Also, to evaluate international normalized ratio (INR), the cutoff value was set at 2. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), and negative likelihood ratio (NLR) of the serum markers were used to describe predictive properties. Of 70 patients, 27 (38.6%) were male and 43 (61.4%) were female, and the mean age was 54.67±15.11 years (range, 18 to 80 years). Of 70 patients, 27 (38.6%) had prosthetic heart valve malfunction demonstrable by fluoroscopy, and 19 patients (27.1%) had D-dimer levels >500 ng/ml. Elevated D-dimer levels (>500 ng/ml) have been indicated to have sensitivity of 70.4%, and hence an NPV of 84.3%, specificity of 100%, PPV of 100%, NLR of 0.3, and the infinity value of PLR for predicting prosthetic valve dysfunction. There was a significant relationship between fluoroscopy and D-dimer test (P=0.001). A kappa coefficient value of 0.745 indicated a substantial agreement between D-dimer and fluoroscopy testing. Mixing test (combination of D-dimer and INR) showed to have 100% sensitivity, and hence a NPV of 69.8%, specificity of 69.8%, PPV of 51.8%, NLR of 1.41, and PLR of 1.44 for predicting prosthetic valve dysfunction. D-dimer with moderate sensitivity and high specificity is an ideal marker for the diagnosis of prosthetic valve dysfunction in suspected patients. Enhanced plasma D-dimer level is not by itself diagnostic of a prosthetic valve dysfunction but may alert physicians to refer the patient for more detailed examination, preferably by fluoroscopy. Mixing test with 100% sensitivity can apply as a rule-out test.

A potential misdiagnosis in the COVID-19 pandemic era: a case report of superimposed thrombosis or tumor recurrence

BackgroundThe clinical manifestations of coronavirus disease 2019 (COVID-19) overlap with those of other disorders, especially cardiovascular disease.Case presentationWe herein describe a 58-year-old woman who presented with syncopal episodes and dyspnea on exertion with a left atrial (LA) mass, scheduled for surgical removal and mitral valve replacement. Nearly 3 months later, the patient developed dyspnea, fever, and a sore throat, resulting in hospital admission with suspected COVID-19. During the diagnostic evaluation, a larger LA mass was detected. The mass seemed to be a COVID-19–induced organized thrombus with prosthetic mitral valve malfunction. Resection was, therefore, planned. An immunohistochemistry study revealed a liposarcoma.ConclusionsThe unusual early recurrence of liposarcomas and the misdiagnosis with COVID-19–induced thrombosis are the hallmark of the present case.

Risk Factors Associated with Heart Valve Thrombosis in Patients with Prosthetic Heart Valve Dysfunction.

Thrombotic and thromboembolic events are important causes of mortality and morbidity in patients with prosthetic heart valve. The aim of this study is to evaluate the factors that may contribute to prosthetic heart valve thrombosis. This was a cross-sectional study in Rajaie Heart Center on patients with prosthetic heart valve malfunction, within a year. According to the echocardiographic and fluoroscopic findings, the patients were divided into two groups (thrombosis and non-thrombosis groups). The patients' demographic, clinical and laboratory data were recorded and analyzed with SPSS software. A total of 142 patients participated in this study. Ninety-four patients (66.2%) were diagnosed with thrombosis. There was a significant relationship between thrombosis and inadequate anti-coagulation (international normalized rati [INR] <2.5) (odds ratio [OR]: 4.15, 95% CI: 1.98-9.87, P = 0.003), history of infection (OR: 12.81, 95% CI: 3.52-19.02, P<0.001), prothrombin time (PT) check interval (OR: 2.38, 95% CI: 1.63-8.47, P = 0.019), atrial fibrillation (AF) rhythm (OR: 3.96, 95% CI: 1.75-8.09, P = 0.019), and plasma fibrinogen level (OR: 6.90, 95% CI: 2.58-14.69). Based on this study, inadequate anti-coagulation, AF rhythm, recent infection and plasma fibrinogen level were the factors most contributing to prosthetic valve thrombosis. As there were many cases of thrombosis in patients with history of infection, this factor can be considered for risk assessment in prosthetic valve.

Esolution of a high risk AV prosthetic valve malfunction after fibrinolytic therapy; a case report

esolution of a high risk AV prosthetic valve malfunction after fibrinolytic therapy; a case report

Early Prosthetic Valve Malfunction Leading to Cardiogenic Shock and Emergency Redo Mitral Valve Replacement

Early onset prosthetic valve stenosis is an uncommon complication after valve replacement surgery and is often caused by thrombus formation. Frequently it can be diagnosed by echocardiography and managed with optimizing anticoagulation and/or thrombolysis. We review a unique case of early bi-leaflet mechanical heart valve (BMHV) dysfunction where the patient rapidly progressed to cardiogenic shock requiring emergent re-do mitral valve surgery. Intraoperatively, the valve leaflets were found to be almost completely immobile secondary to thrombus formation directly on the hinges of the valve. This case demonstrates how the leaflet orientation of a BMHV affects transmitral flow and fluid dynamics. Furthermore, we also discuss left atrial vortex formation in the setting of atrial fibrillation, kinetic energy transfer through an anatomically implanted mechanical mitral valve, and their roles in contributing to early prosthetic valve thrombosis despite adequate anticoagulation.

Corrigendum to: Mechanical prosthetic valve malfunction diagnosed by gated non-contrast computed tomography.

Corrigendum to: Mechanical prosthetic valve malfunction diagnosed by gated non-contrast computed tomography.

Mid-term outcomes of mechanical pulmonary valve replacement: a single-institutional experience of 396 patients

Previous small-sized studies have demonstrated the safety and efficacy of mechanical pulmonary valve replacement (mPVR) in patients with congenital heart disease; however, the predictors of major complications and reoperation remained unclear. In a retrospective study, we reported the mid-term outcomes of a large-scaled series of patients, 396 patients, with congenital heart diseases who underwent mPVR in a single institution. The patients' mean age at mPVR was 24.3 ± 9years (4-58years). Most patients (84.3%) underwent tetralogy of Fallot total correction. The median of follow-up was 36months (24-49months). Prosthetic valve malfunction caused by thrombosis or pannus formation developed in 12.1% of patients during follow-up period. Reoperation was performed in 7 cases with pannus formation and 6 cases with mechanical valve thrombosis. Freedom from reoperation at 1, 5, and 10years was 99%, 97%, and 96%, respectively. Neither early nor mid-term mortalities were detected. Cox regression models showed that male gender and smaller valve size increased the risk of prosthetic valve failure. The age at mPVR, interval between congenital heart defect repair and mPVR, and concomitant procedures predicted reoperation. In multivariate analysis, younger age and the interval between first operation and mPVR predicted reoperation either. The success rate of mPVR is excellent in mid-term follow-up. Younger age, longer interval between the repair of congenital defect and mPVR, and cooperation increased reoperation risk. However, strict adherence to life-long anticoagulation regimen and patient selection are of great importance for the implementation of mPVR.

Prosthetic mitral valve thrombosis, malfunction, and paroxysmal mitral regurgitation

Intermittent dysfunction of mechanical mitral valve prosthesis is an uncommon condition. It carries serious clinical implications if unrecognized. Here, we present a case of a 28-year-old female with a history of rheumatic multivalvular disease, for which she had undergone double valve replacement and tricuspid annuloplasty. Six months later, she presented with heart failure. Clinical examination revealed intermittent loss of closing clicks followed by a pansystolic murmur at the apex, suggestive of mitral prosthetic valve dysfunction. We highlight the echocardiographic findings of paroxysmal mitral valvular regurgitation secondary to prosthetic valve malfunction secondary to prosthetic valve thrombosis.

Emergency surgery for prosthetic mitral valve dysfunction: risk factors and technical consideration

Objective Prosthetic mitral valve dysfunction remains a devastating complication in heart surgery. This study aims to assess the risk factors and the technical approaches to reach the best way to deal with and improve the outcome in these patients. Patients and methods Between January 2002 and March 2005, 60 patients underwent emergency reoperation for prosthetic mitral valve dysfunction, where 36 (60%) patients were in New York Heart Association class III, and 24 (40%) patients were in New York Heart Association class IV. There were 33 (55%) male and 27 (45%) female patients. The mean age at operation was 32.4 ± 6.3 years. Nine (15%) patients presented with fever. Hemodynamic status was unstable in 18 (30%) patients. Surgery has been carried out through repeat sternotomy or right anterolateral thoracotomy. Results The 30-day mortality rate was 12 (20%) patients. Analysis of preoperative, intraoperative, and postoperative factors revealed that significant predictors of early mortality were the surgical approach, time until surgical intervention, and depression of left ventricular function. The cause of prosthetic mitral valve malfunction was valve thrombosis in 39 (65%) patients, pannus formation in nine (15%) patients, paravalvular leakage in three (5%) patients, and prosthetic valve endocarditis (PVE) in nine (15%) patients. Right anterolateral thoracotomy (24.3 ± 8.5 min) proved to be faster than median sternotomy (63.1 ± 63 min) from skin incision to on bypass with a significant reduction of intraoperative complications and postoperative wound infections. Conclusion Hospital mortality can be reduced in patients with prosthetic mitral valve dysfunction if the surgery is carried out before cardiac dysfunction develops, with excellent results. Right anterolateral thoracotomy is feasible and safe for selected patients and should be considered whenever repeat median sternotomy could prove to be hazardous especially in the prominent right ventricle and pulmonary hypertension.

Clinical Implication of Transaortic Mitral Pannus Removal During Repeat Cardiac Surgery for Patients With Mechanical Mitral Valve.

This study aimed to evaluate the safety and feasibility of transaortic mitral pannus removal (TMPR).Methods and Results:Between 2004 and 2016, 34 patients (median age, 57 years; 30 women) with rheumatic disease underwent pannus removal on the ventricular side of a mechanical mitral valve through the aortic valve during reoperation. The median time interval from the previous surgery was 14 years. TMPR was performed after removal of the mechanical aortic valve (n=21) or diseased native aortic valve (n=11). TMPR was performed in 2 patients through a normal aortic valve. The mitral transprosthetic mean pressure gradient (TMPG) was ≥5 mmHg in 11 patients, including 3 with prosthetic valve malfunction. Prophylactic TMPR was performed in 23 patients. There were no early deaths. Concomitant operations included 22 tricuspid valve surgeries (13 replacements, 15 repairs) and 32 aortic valve replacements (24 repeats, 8 primary). The mean gradient in patients who had mitral TMPG ≥5 mmHg was significantly decreased from 6.46±1.1 to 4.37±1.17 mmHg at discharge (P<0.001). No mechanical valve malfunction was apparent on last echocardiography. TMPR is a safe and effective procedure for patients with malfunction or stenosis of a mechanical mitral valve and may be considered an alternative approach in patients with pannus overgrowth in such valves.

Early lotus transcatheter aortic valve thrombosis

Valve thrombosis is an important problem of surgical valves and also newer generation transcatheter valves. Valve thrombosis has been reported in different transcatheter valves, such as Edwards and Corevalve valves. Valve thrombosis after Lotus valve implantation has not been reported. To the best of our knowledge, this is the first report in the literature of a Lotus valve thrombosis. The patient discharged home on aspirin and clopidogrel after procedure, however she became symptomatic soon and the diagnosis of prosthetic valve malfunction due to thrombosis was made. Patient treated with anticoagulant therapy.

Triple valve replacement for rheumatic heart disease: short- and mid-term survival in modern era

Triple valve replacement (TVR) is still deemed a complex and challenging choice for rheumatic heart disease (RHD) and carries significant mortality and morbidity. We report the short- and mid-term results after TVR in the last decade. In a historical cohort, ninety consecutive patients, at a mean age of 47 ± 12 years underwent TVR between 2003 and 2013 for RHD. Most of the patients were in the New York Heart Association (NYHA) functional class II or III. Univariate and multivariate analyses were performed to identify the predictors of overall and event-free survival. The 30-day hospital mortality rate was 6% (n = 5). One-year and 4-year overall survival (cardiac survival) rates were 91.7 and 89.5%, respectively. One-year and 4-year rates of freedom from cardiac events (e.g. cardiac death, cardiac rehospitalization, cardiac reoperation, cerebrovascular events, anticoagulation-related major haemorrhage and significant valvular malfunction) were 83.5 and 69.5%, respectively. Age, diabetes and pump time were the independent predictors of overall survival, and diabetes and hypertension were the independent predictors of event-free survival. One-year and 4-year freedom rates from anticoagulation-related major haemorrhage were 96.6 and 90.7%, respectively. The 1-year and 4-year rates of freedom from a composite of valvular thrombosis, major bleeding events and thromboemboli were 94.1 and 88.5%, respectively. One-year and 4-year freedom rates from cardiac rehospitalization were 94.0 and 88.0%, respectively. One-year and 4-year rates of freedom from cardiac reoperation were 98.8 and 93.9%, respectively. One-year and 4-year rates of freedom from significant prosthetic valve malfunction (e.g. structural valve deterioration, valve thrombosis and paravalvular leakage) were 96.6 and 90.7%, respectively. The 1-year and 4-year rates of freedom from major adverse valve-related events were 86.3 and 78.5%, respectively. TVR for RHD appears to confer satisfactory short- and mid-term results with excellent symptomatic improvement. The overall mortality following TVR may be improved by early surgical treatment before the NYHA functional class IV.

Tricuspid regurgitation after successful mitral valve surgery.

The tricuspid valve (TV) is inseparably connected with the mitral valve (MV) in terms of function. Any pathophysiological condition concerning the MV is potentially a threat for the normal function of the TV as well. One of the most challenging cases is functional tricuspid regurgitation (TR) after surgical MV correction. In the past, TR was considered to progressively revert with time after left-sided valve restoration. Nevertheless, more recent studies showed that TR could develop and evolve postoperatively over time, as well as being closely associated with a poorer prognosis in terms of morbidity and mortality. Pressure and volume overload are usually the underlying pathophysiological mechanisms; structural alterations, like tricuspid annulus dilatation, increased leaflet tethering and right ventricular remodelling are almost always present when regurgitation develops. The most important risk factors associated with a higher probability of late TR development involve the elderly, female gender, larger left atrial size, atrial fibrillation, right chamber dilatation, higher pulmonary artery systolic pressures, longer times from the onset of MV disease to surgery, history of rheumatic heart disease, ischaemic heart disease and prosthetic valve malfunction. The time of TR manifestation can be up to 10 years or more after an MV surgery. Echocardiography, including the novel 3D Echo techniques, is crucial in the early diagnosis and prognosis of future TV disease development. Appropriate surgical technique and timing still need to be clarified.

Ex vivo hemodynamic assessment of mechanical aortic valve gradients using a high‐fidelity pressure wire

Accurate assessment of prosthetic mechanical valve malfunction is challenging for non-invasive and invasive techniques. We evaluated a 0.014-inch pressure-sensing coronary guidewire to assess mechanical valve dysfunction. Several case reports have shown that transaortic pressure gradients can be recorded using a 0.014-inch guidewire during cardiac catheterization. We performed an ex vivo study measuring the effects of sequentially crossing the center of each valve with a 6 French coronary angiographic catheter, a 0.035-inch guidewire, and a 0.014-inch pressure-sensing guidewire on valve dysfunction using the following 23 mm bileaflet and tilting-disc aortic valves: St. Jude Regent™, CarboMedics, Medtronic Hall™, and Björk-Shiley Monostut. A left heart model pulse duplicator recorded 10 consecutive cycles. For all valves, the greatest increase in valve regurgitation occurred with the 6 French catheter, causing a reduction in aortic valve back pressure and cardiac output, with an increase in leakage rate, regurgitant fraction, and energy loss. In comparison to the 0.035-inch guidewire, the 0.014-inch guidewire had greater regurgitation for St. Jude, lower for Medtronic Hall, and equivalent for CarboMedics and Björk-Shiley valves. For the CarboMedics valve, the 0.035-inch guidewire caused a significant increase in regurgitant fraction and energy loss, while the pressure wire had no change compared to baseline. The degree of regurgitation caused by the 0.014-inch guidewire varies with the type of mechanical aortic valve. While prior case reports have shown that valve hemodynamics may be measured using a pressure-sensing guidewire, valve regurgitation occurs when crossing a St. Jude, Medtronic Hall, or Björk-Shiley aortic valve.

Transaortic chordae and pannus removal without redo mitral valve replacement in prosthetic mitral valve malfunction

Both anterior and posterior chordae of the mitral valve are occasionally spared during mitral valve surgery to preserve left ventricular function. In this report, a 43-year-old woman who had undergone mitral valve replacement surgery with anterior and posterior chordal preservation 9 years ago subsequently had mitral valve pannus and anterior chordae covering the prosthetic valve, which led to valve malfunction. Prosthetic mitral valve function was successfully recovered by performing transaortic pannus and chordae removal, avoiding redo mitral valve replacement.

Prosthetic Valve Malfunction Caused by Chordal Entrapment Detected by Transesophageal Echocardiography

Prosthetic Valve Malfunction Caused by Chordal Entrapment Detected by Transesophageal Echocardiography

Giant left atrium in a woman with mitral prosthetic valve malfunction and history of rheumatic heart disease

Giant left atrium in a woman with mitral prosthetic valve malfunction and history of rheumatic heart disease

The double sewing ring technique: a not so easy reoperation!

This recently published article by Albertini et al. [1] beautifully depicts the modified Bentall operation: the double sewing ring technique. We have made use of a similar technique for years, but unfortunately it does not mean that it renders the use of bioprosthetic valves any easier. We had two patients with prosthetic valve malfunction, which necessitated valve replacement. Surgery proved problematic, however, because even utilizing a Valsalva tube did not reduce the probability of the dehiscence of the coronary ostia or the whole graft. The present manuscript states that neither patient required reoperation, but we are inclined to believe that the patients in question will refer to the hospital in the near future for the same problem. We employ this technique for patients with small aortic annuluses or for patients who need root enlargement because, as the manuscript itself attests, not only does this independent selection of graft and valve size minimize the chance of valve-to-graft mismatch but also the use of smaller size sutures decreases the probability of bleeding. In conclusion, although this technique is suitable for small or calcified annuluses, we fear that an extensive use of this technique with bioprosthetic valves could beget trouble. Consequently, it is advisable that this technique not be recommended for the time being until the patients’ followup is complete. Reference

An unusual complication following mitral valve surgery and use of intra-operative transoesophageal echocardiography

Prosthetic leaflet immobilisation has been described in mitral valve prostheses following mitral valve replacement surgery.[1] Stuck or immobile prosthetic valve is a relatively uncommon condition and it is a potentially life-threatening complication of mitral valve replacement surgery. Transoesophageal echocardiography (TOE) has been instrumental in the early detection of prosthetic valve malfunction following cardiopulmonary bypass.[2]