Case report
Perivalvular pannus and valve thrombosis: Two concurrent mechanisms of mechanical valve prosthesis dysfunction
Pannus peri-valvular e trombose valvular: ocorrência de um duplo mecanismo para a disfunção de prótese valvular mitral mecânica
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Bueno-Codoñer, Javier López-Rodríguez, María José Dalmau-Sorlí, Adolfo Arévalo-Abascal, Antonio Arribas-Jiménez, Alejandro Diego-Nieto, Javier Rodríguez-Collado, Jose María Rodríguez-López" "autores" => array:10 [ 0 => array:4 [ "nombre" => "María Elena" "apellidos" => "Arnáiz-García" "email" => array:1 [ 0 => "elearnaiz@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Jose María" "apellidos" => "González-Santos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "María E." 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The shape of pannus growth on the ventricular surface of the prosthesis removed from the prosthesis can be clearly seen. The concentric stenosis of the valve orifice area (black arrow) and the thrombosis on the atrial side causing valve blockage (white arrow) are evident. The mural blood clot removed from the left atrial appendage is shown.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 78-year-old woman with a history of hypertension and diabetes was admitted to our institution with a one-year history of progressive dyspnea. Ten years previously she had been diagnosed with rheumatic heart disease and atrial fibrillation and had undergone mitral valve replacement with a 25-mm Carbomedics bileaflet mechanical valve. She had been asymptomatic until two months ago, when she reported dyspnea (New York Heart Association class III), orthopnea, and weight gain. Physical examination revealed cardiac arrhythmia and signs of decompensated heart failure (ascites and lower limb edema). Laboratory tests showed no abnormalities. The electrocardiogram confirmed atrial fibrillation. An echocardiogram revealed restricted motion of the mitral leaflets (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A), with partial thrombosis of the mitral prosthesis and a blockage of the posterior mechanical prosthesis disc. A high transmitral gradient was observed by transesophageal echocardiography. A left atrial (LA) mural thrombus, moderately depressed left ventricular ejection fraction (45%), severe pulmonary artery hypertension (systolic pulmonary artery pressure of 70 mmHg), and severe functional tricuspid regurgitation were also detected. A coronary angiogram confirmed an immobile prosthetic leaflet (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B and 1C). No lesions were seen in the main coronary arteries. The patient was scheduled for cardiac surgery.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Through median resternotomy, adherences from the previous surgery were carefully released. Cardiopulmonary bypass was established with bicaval venous cannulation. Through transseptal access, the mitral prosthesis was accessed and examined. Intraoperatively, a 3×3 cm thrombus was removed from the origin of the left atrial appendage (not closed during the first cardiac operation) and in immediate contact with the mechanical valve (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>D). A partial thrombosis was observed around the mechanical valve and an immobile prosthesis disc was seen. The mitral prosthesis was replaced and the mechanical valve was excised, revealing circumferential mitral prosthesis obstruction due to pannus growing within the valve orifice on the ventricular surface of the prosthesis. The valve was replaced with a 31-mm Labcor mitral bioprosthesis and tricuspid annuloplasty was also performed. Echocardiographic monitoring confirmed that the mitral prosthesis was functioning correctly without leakage after placement. Postoperatively, the patient recovered uneventfully and was discharged home nine days after surgery with greater exercise tolerance and progressive improvement.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Prosthetic heart valve blockage is a rare but life-threatening complication after valve replacement.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> The main causes are thrombosis of the prosthesis, the formation of pannus around the valve, or a combination of both mechanisms.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Thrombosis after heart valve replacement is not a rare entity; it is usually associated with lower rates of anticoagulation but may result in severe hemodynamic compromise.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> However, thrombi must be differentiated from pannus. Pannus is fibrotic tissue that grows around artificial valves, usually in an annular location, in response to blood stasis and local inflammation after surgery.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Its growth basically depends on the patient and valve type, design, size and location (it is more frequent on aortic than mitral prostheses, and when observed in mitral position, is usually located on the atrial side of the prosthesis). In cases of excessive pannus formation, a leaflet or the entire prosthesis can be blocked. The presence of pannus can predispose to valve thrombosis, and chronic thrombosis of a heart valve can also trigger pannus formation.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Symptoms are variable depending of the severity of valve dysfunction.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–5</span></a> Severe and acute valve obstruction due to thrombosis can cause severe heart failure, embolic events or death.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–5</span></a> In cases with partial or chronic valve obstruction, as usually occurs with pannus, the diagnosis is sometimes delayed due to the non-specific nature of signs such as fatigue, shortness of breath and discomfort.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Suspicion of an obstructed prosthetic valve warrants rapid diagnostic assessment. Optimal management remains controversial. The therapeutic strategy will be influenced by prosthesis location, severity of valve obstruction, and the patient's clinical status. Repeat surgery is the first-line therapy in symptomatic mechanical valve obstruction, critically ill patients or cases of recurrent prosthesis thrombosis despite adequate anticoagulation.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–5</span></a> In non-obstructive cases, thrombolytic or fibrinolytic therapy is a feasible alternative to surgery, but bleeding complications must be considered.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> A combination of heparin and aspirin has also been considered as an alternative treatment in stable patients in whom inadequate anticoagulation has been confirmed and when surgery or fibrinolysis is not available or indicated due to high-risk comorbidities.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Echocardiographic monitoring is mandatory in these alternative treatments to monitor thrombosis development.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In this case report we show the simultaneous occurrence of two causal mechanisms of mechanical valve dysfunction that are usually misdiagnosed and confused, but rarely concurrent, and a common result: blockage of a mitral prosthesis.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ethical disclosures</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Protection of human and animal subjects</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Confidentiality of data</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Right to privacy and informed consent</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres439411" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec462601" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres439412" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec462600" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Right to privacy and informed consent" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-07-09" "fechaAceptado" => "2014-08-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec462601" "palabras" => array:5 [ 0 => "Mitral" 1 => "Prosthesis" 2 => "Thrombosis" 3 => "Pannus" 4 => "Mechanical valve dysfunction" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec462600" "palabras" => array:5 [ 0 => "Mitral" 1 => "Prótese" 2 => "Trombose" 3 => "<span class="elsevierStyleItalic">Pannus</span>" 4 => "Disfunção valvar mecânica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 78-year-old woman was admitted to our institution with progressive dyspnea. She had previously been diagnosed with rheumatic heart disease and had undergone cardiac surgery for mechanical mitral valve replacement ten years previously. Transesophageal echocardiography revealed blockage of the mechanical prosthesis and the patient was scheduled for surgery, in which a thrombus was removed from the left atrial appendage. A partial thrombosis of the mechanical prosthesis and circumferential pannus overgrowth were concomitantly detected. Prosthetic heart valve blockage is a rare but life-threatening complication, the main causes of which are thrombosis and pannus formation. The two conditions are different but both are usually misdiagnosed. Two concurrent mechanisms of prosthesis blockage were found in this patient.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Uma mulher de 78 anos de idade, foi admitida na nossa instituição com dispneia progressiva. Foi-lhe previamente diagnosticada doença reumática, tendo sido submetida a cirurgia cardíaca de substituição de válvula mitral por prótese mecânica há dez anos. O ecocardiograma transesofágico revelou um bloqueio da prótese mecânica. A paciente foi referida para a cirurgia, tendo sido removido um trombo do apêndice atrial esquerdo. A trombose parcial de prótese mecânica e o crescimento circunferencial de <span class="elsevierStyleItalic">pannus</span> ocorreram concomitantemente. O bloqueio das válvulas cardíacas protésicas é uma complicação rara mas potencialmente fatal. As principais causas são a trombose ou formação de <span class="elsevierStyleItalic">pannus</span>. As duas condições são diferentes, mas em regra erradamente diagnosticadas. Nesta paciente foi detetado um duplo mecanismo de bloqueio de prótese.</p></span>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1584 "Ancho" => 2167 "Tamanyo" => 500258 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram (A) and fluoroscopy (B and C) showing impaired motion of the two leaflets due to associated pannus and thrombosis; (D) explanted mechanical mitral valve. The shape of pannus growth on the ventricular surface of the prosthesis removed from the prosthesis can be clearly seen. The concentric stenosis of the valve orifice area (black arrow) and the thrombosis on the atrial side causing valve blockage (white arrow) are evident. The mural blood clot removed from the left atrial appendage is shown.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Thrombosis of prosthetic heart valves: diagnosis and therapeutic considerations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R. Roudaut" 1 => "K. Serri" 2 => "S. Lafitte" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/hrt.2005.071183" "Revista" => array:6 [ "tituloSerie" => "Heart" "fecha" => "2007" "volumen" => "93" "paginaInicial" => "137" "paginaFinal" => "142" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17170355" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful thrombolytic treatment of prosthetic mitral valve thrombosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E. Gazi" 1 => "B. Altun" 2 => "A. Temiz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bcr-2013-009917" "Revista" => array:2 [ "tituloSerie" => "BMJ Case Rep" "fecha" => "2013" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Unusual cause of stroke after mitral valve replacement" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.Y. Tabet" 1 => "E. Bouvier" 2 => "B. Cormier" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.110.945014" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2010" "volumen" => "122" "paginaInicial" => "e484" "paginaFinal" => "e485" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20937984" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Obstruction of St Jude Medical valves in the aortic position: histology and immunohistochemistry of pannus" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "H. Teshima" 1 => "N. Hayashida" 2 => "H. Yano" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "2003" "volumen" => "126" "paginaInicial" => "401" "paginaFinal" => "407" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12928636" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute thrombosis of mechanical bi-leaflet aortic valve prosthesis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "T. Tirolimis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/0975-3583.98899" "Revista" => array:6 [ "tituloSerie" => "J Cardiovasc Dis Res" "fecha" => "2012" "volumen" => "3" "paginaInicial" => "228" "paginaFinal" => "230" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22923942" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003400000002/v2_201502270337/S2174204915000367/v2_201502270337/en/main.assets" "Apartado" => array:4 [ "identificador" => "9919" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003400000002/v2_201502270337/S2174204915000367/v2_201502270337/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204915000367?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
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| 2018 April | 85 | 13 | 98 |
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| 2016 September | 64 | 9 | 73 |
| 2016 August | 39 | 1 | 40 |
| 2016 July | 17 | 6 | 23 |
| 2016 June | 29 | 2 | 31 |
| 2016 May | 22 | 2 | 24 |
| 2016 April | 30 | 2 | 32 |
| 2016 March | 40 | 9 | 49 |
| 2016 February | 41 | 22 | 63 |
| 2016 January | 26 | 20 | 46 |
| 2015 December | 13 | 9 | 22 |
| 2015 November | 36 | 12 | 48 |
| 2015 October | 31 | 17 | 48 |
| 2015 September | 36 | 10 | 46 |
| 2015 August | 49 | 20 | 69 |
| 2015 July | 45 | 9 | 54 |
| 2015 June | 35 | 10 | 45 |
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| 2015 April | 54 | 25 | 79 |
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