Image in Cardiology
Hanging by a thread: Major detachment of an aortic prosthetic valveHanging by a thread
Deiscência grave de prótese mecânica aórtica
Jennifer Mancioa,
, Carla Almeidab, Gustavo Pires-Moraisc, Lino Santosc, Bruno Melicac, Marco Oliveirac, Alberto Rodriguesc, Pedro Bragac, Vasco Gama Ribeiroc
Corresponding author
a Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho and Cardiovascular R&D Unit, Department of Physiology and Cardiothoracic Surgery of Medical School of Porto, Portugal
b Department of Cardiology, Hospital do Divino Espirito Santo, Ponta Delgada, Portugal
c Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, Portugal
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"entidad" => "Department of Cardiology, Hospital do Divino Espirito Santo, Ponta Delgada, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Deiscência grave de prótese mecânica aórtica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 855 "Ancho" => 1719 "Tamanyo" => 183410 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cardiac fluoroscopy (left anterior oblique view) showing systolic (A) and diastolic (B) position of the aortic prosthesis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">We report the case of a 62-year-old man with a previous mechanical aortic valve prosthesis who was referred for emergent cardiac catheterization after successful resuscitation from an out-of-hospital pulseless electrical activity cardiac arrest. Post-resuscitation, the patient was comatose with arterial blood pressure 60/35 mmHg, and the electrocardiogram showed widespread ST-segment depression and ST-elevation elevation in lead aVR. Mechanical ventilation, inotropic and vasopressor support were initiated during the transfer to a percutaneous coronary intervention-capable hospital. Cardiac fluoroscopy showed pivotal movement of the aortic prosthesis with each heartbeat and severe regurgitation was seen on aortography (Video 1). Prosthesis position in systole (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A) and diastole (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B) was demonstrated in individual cinefluoroscopic frames (left anterior oblique view). In diastole, the blood regurgitated into the left ventricular cavity produced a 90° clockwise rotation of the aortic prosthesis. Coronary angiography was normal. The patient underwent emergent cardiac surgery, during which the intraoperative transesophageal echocardiogram showed a large nodular structure suggestive of vegetation at the aortic prosthesis leaflet in addition to severe aortic regurgitation (Video 2). Macroscopically, the prosthesis was found to be three-fourths detached and there were ring and perivalvular tissue vegetations with annular abscesses. Excision and replacement of the dehisced aortic valve was performed. Methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> was grown from peripheral blood and prosthetic material cultures. After completing four weeks of vancomycin therapy, the patient was discharged home asymptomatic.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Prosthetic aortic valve detachment is a rare complication, occurring in 0.1%–1.3% of patients who undergo aortic valve replacement.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> The known risk factors for detachment are bacterial endocarditis, concomitant aneurysm of the ascending aorta, and severe calcification of the native aortic valve. Although echocardiography is the modality of choice for evaluating cardiac valves, assessment of mechanical prosthetic valve function by echocardiography is sometimes difficult. The value of gradients in isolation is limited, since gradients depend not only on flow magnitude but also on valve type and size.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a> High transprosthetic velocity alone is not proof of intrinsic aortic valve prosthesis obstruction, but may be secondary to high flow, prosthesis-patient mismatch, or pressure recovery at the smaller central valvular orifice. Conversely, high transprosthetic gradients may not be evident in cases of low cardiac output, even in the presence of obstruction.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a> In cases of suspected dysfunctional prosthesis, visualization of prosthetic leaflet motion can help in differential diagnosis. However, the ability of echocardiography to visualize prosthesis disc motion is limited by the acoustic shadowing caused by the prosthetic valve itself.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Our case demonstrates that fluoroscopy permits rapid and easy evaluation of mechanical prosthetic valve function, enabling normal and dysfunctional prostheses to be distinguished. It has been demonstrated that fluoroscopy, particularly in aortic position, is superior to two-dimensional echocardiography in identifying disc motion, and so for this purpose, cinefluoroscopy is considered the gold standard technique.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a> In conclusion, cinefluoroscopy rapidly provides valuable information to assess prosthetic valve function which is complementary to that obtained by echocardiography.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Ethical disclosures</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Protection of human and animal subjects</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Confidentiality of data</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Right to privacy and informed consent</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 1 => array:3 [ "identificador" => "sec0010" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Right to privacy and informed consent" ] ] ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0045" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary material" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 855 "Ancho" => 1719 "Tamanyo" => 183410 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cardiac fluoroscopy (left anterior oblique view) showing systolic (A) and diastolic (B) position of the aortic prosthesis.</p>" ] ] 1 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 1336617 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] ] ] ] 2 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 1591613 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recommendations for evaluation of prosthetic valves with echocardiography and Doppler ultrasound" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "W.A. Zoghbi" 1 => "J.B. Chambers" 2 => "J.G. Dumesnil" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.echo.2009.07.013" "Revista" => array:6 [ "tituloSerie" => "J Am Soc Echocardiogr" "fecha" => "2009" "volumen" => "22" "paginaInicial" => "975" "paginaFinal" => "1014" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19733789" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of prosthetic aortic valve design on the Doppler-catheter gradient correlation: an in vitro study of normal St. Jude, Medtronic-Hall, Starr-Edwards and Hancock valves" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "H. Baumgartner" 1 => "S. Khan" 2 => "M. DeRobertis" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "1992" "volumen" => "19" "paginaInicial" => "324" "paginaFinal" => "332" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1531058" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0030" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Feasibility and diagnostic accuracy of quantitative assessment of mechanical prostheses leaflet motion by transthoracic and transesophageal echocardiography in suspected prosthetic valve dysfunction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Muratori" 1 => "P. Montorsi" 2 => "G. Teruzzi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjcard.2005.07.112" "Revista" => array:6 [ "tituloSerie" => "Am J Cardiol" "fecha" => "2006" "volumen" => "97" "paginaInicial" => "94" "paginaFinal" => "100" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16377291" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003400000012/v2_201704020102/S2174204915002871/v2_201704020102/en/main.assets" "Apartado" => array:4 [ "identificador" => "9915" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Images in cardiology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003400000012/v2_201704020102/S2174204915002871/v2_201704020102/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204915002871?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 20 | 3 | 23 |
| 2024 October | 148 | 34 | 182 |
| 2024 September | 143 | 22 | 165 |
| 2024 August | 157 | 25 | 182 |
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| 2023 December | 33 | 33 | 66 |
| 2023 November | 35 | 29 | 64 |
| 2023 October | 25 | 15 | 40 |
| 2023 September | 16 | 17 | 33 |
| 2023 August | 17 | 13 | 30 |
| 2023 July | 17 | 9 | 26 |
| 2023 June | 18 | 17 | 35 |
| 2023 May | 25 | 25 | 50 |
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| 2023 March | 262 | 19 | 281 |
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| 2021 December | 19 | 26 | 45 |
| 2021 November | 31 | 27 | 58 |
| 2021 October | 20 | 37 | 57 |
| 2021 September | 22 | 31 | 53 |
| 2021 August | 23 | 24 | 47 |
| 2021 July | 16 | 26 | 42 |
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| 2021 May | 25 | 31 | 56 |
| 2021 April | 41 | 35 | 76 |
| 2021 March | 49 | 15 | 64 |
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| 2020 December | 25 | 5 | 30 |
| 2020 November | 26 | 14 | 40 |
| 2020 October | 13 | 12 | 25 |
| 2020 September | 47 | 17 | 64 |
| 2020 August | 29 | 7 | 36 |
| 2020 July | 49 | 12 | 61 |
| 2020 June | 28 | 3 | 31 |
| 2020 May | 24 | 5 | 29 |
| 2020 April | 30 | 21 | 51 |
| 2020 March | 36 | 10 | 46 |
| 2020 February | 30 | 22 | 52 |
| 2020 January | 22 | 5 | 27 |
| 2019 December | 29 | 7 | 36 |
| 2019 November | 22 | 6 | 28 |
| 2019 October | 11 | 7 | 18 |
| 2019 September | 24 | 11 | 35 |
| 2019 August | 25 | 4 | 29 |
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| 2019 June | 20 | 8 | 28 |
| 2019 May | 23 | 10 | 33 |
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| 2019 March | 38 | 10 | 48 |
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| 2019 January | 24 | 4 | 28 |
| 2018 December | 30 | 11 | 41 |
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| 2018 October | 66 | 17 | 83 |
| 2018 September | 30 | 17 | 47 |
| 2018 August | 24 | 3 | 27 |
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| 2018 June | 22 | 4 | 26 |
| 2018 May | 28 | 10 | 38 |
| 2018 April | 40 | 4 | 44 |
| 2018 March | 47 | 5 | 52 |
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| 2017 June | 21 | 8 | 29 |
| 2017 May | 25 | 3 | 28 |
| 2017 April | 37 | 2 | 39 |
| 2017 March | 38 | 43 | 81 |
| 2017 February | 26 | 4 | 30 |
| 2017 January | 34 | 1 | 35 |
| 2016 December | 30 | 9 | 39 |
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| 2016 October | 29 | 4 | 33 |
| 2016 September | 23 | 5 | 28 |
| 2016 August | 11 | 1 | 12 |
| 2016 July | 17 | 3 | 20 |
| 2016 June | 21 | 8 | 29 |
| 2016 May | 18 | 2 | 20 |
| 2016 April | 11 | 16 | 27 |
| 2016 March | 8 | 14 | 22 |
| 2016 February | 26 | 22 | 48 |
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