Image in Cardiology
Hanging by a thread: Major detachment of an aortic prosthetic valve
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
Autor para correspondência
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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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" => 845 "Ancho" => 1700 "Tamanyo" => 176076 ] ] "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 "fechaRecibido" => "2015-04-13" "fechaAceptado" => "2015-07-24" "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" => 845 "Ancho" => 1700 "Tamanyo" => 176076 ] ] "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 [ "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 2 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 1591613 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" ] "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "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" => "/08702551/0000003400000012/v1_201512210110/S0870255115002747/v1_201512210110/en/main.assets" "Apartado" => array:4 [ "identificador" => "357" "tipo" => "SECCION" "pt" => array:2 [ "titulo" => "Imagens em cardiologia" "idiomaDefecto" => true ] "idiomaDefecto" => "pt" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003400000012/v1_201512210110/S0870255115002747/v1_201512210110/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255115002747?idApp=UINPBA00004E" ]
| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 7 | 5 | 12 |
| 2024 Outubro | 71 | 27 | 98 |
| 2024 Setembro | 77 | 20 | 97 |
| 2024 Agosto | 75 | 25 | 100 |
| 2024 Julho | 67 | 26 | 93 |
| 2024 Junho | 56 | 18 | 74 |
| 2024 Maio | 70 | 20 | 90 |
| 2024 Abril | 55 | 34 | 89 |
| 2024 Maro | 65 | 19 | 84 |
| 2024 Fevereiro | 66 | 22 | 88 |
| 2024 Janeiro | 61 | 25 | 86 |
| 2023 Dezembro | 49 | 28 | 77 |
| 2023 Novembro | 59 | 26 | 85 |
| 2023 Outubro | 63 | 26 | 89 |
| 2023 Setembro | 53 | 23 | 76 |
| 2023 Agosto | 67 | 23 | 90 |
| 2023 Julho | 75 | 5 | 80 |
| 2023 Junho | 57 | 12 | 69 |
| 2023 Maio | 76 | 28 | 104 |
| 2023 Abril | 49 | 4 | 53 |
| 2023 Maro | 157 | 22 | 179 |
| 2023 Fevereiro | 151 | 26 | 177 |
| 2023 Janeiro | 146 | 24 | 170 |
| 2022 Dezembro | 161 | 30 | 191 |
| 2022 Novembro | 177 | 23 | 200 |
| 2022 Outubro | 145 | 23 | 168 |
| 2022 Setembro | 154 | 34 | 188 |
| 2022 Agosto | 139 | 26 | 165 |
| 2022 Julho | 193 | 36 | 229 |
| 2022 Junho | 162 | 24 | 186 |
| 2022 Maio | 264 | 39 | 303 |
| 2022 Abril | 481 | 29 | 510 |
| 2022 Maro | 502 | 45 | 547 |
| 2022 Fevereiro | 483 | 25 | 508 |
| 2022 Janeiro | 604 | 32 | 636 |
| 2021 Dezembro | 492 | 29 | 521 |
| 2021 Novembro | 524 | 34 | 558 |
| 2021 Outubro | 663 | 41 | 704 |
| 2021 Setembro | 519 | 33 | 552 |
| 2021 Agosto | 466 | 39 | 505 |
| 2021 Julho | 307 | 24 | 331 |
| 2021 Junho | 423 | 31 | 454 |
| 2021 Maio | 267 | 34 | 301 |
| 2021 Abril | 240 | 42 | 282 |
| 2021 Maro | 104 | 22 | 126 |
| 2021 Fevereiro | 119 | 20 | 139 |
| 2021 Janeiro | 69 | 14 | 83 |
| 2020 Dezembro | 57 | 12 | 69 |
| 2020 Novembro | 105 | 18 | 123 |
| 2020 Outubro | 75 | 12 | 87 |
| 2020 Setembro | 122 | 40 | 162 |
| 2020 Agosto | 117 | 10 | 127 |
| 2020 Julho | 75 | 10 | 85 |
| 2020 Junho | 68 | 12 | 80 |
| 2020 Maio | 84 | 4 | 88 |
| 2020 Abril | 105 | 16 | 121 |
| 2020 Maro | 95 | 9 | 104 |
| 2020 Fevereiro | 168 | 34 | 202 |
| 2020 Janeiro | 45 | 5 | 50 |
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| 2019 Novembro | 43 | 5 | 48 |
| 2019 Outubro | 52 | 7 | 59 |
| 2019 Setembro | 54 | 11 | 65 |
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| 2019 Janeiro | 48 | 3 | 51 |
| 2018 Dezembro | 63 | 18 | 81 |
| 2018 Novembro | 83 | 12 | 95 |
| 2018 Outubro | 122 | 28 | 150 |
| 2018 Setembro | 58 | 10 | 68 |
| 2018 Agosto | 36 | 15 | 51 |
| 2018 Julho | 27 | 4 | 31 |
| 2018 Junho | 42 | 7 | 49 |
| 2018 Maio | 38 | 8 | 46 |
| 2018 Abril | 48 | 5 | 53 |
| 2018 Maro | 93 | 11 | 104 |
| 2018 Fevereiro | 26 | 9 | 35 |
| 2018 Janeiro | 57 | 2 | 59 |
| 2017 Dezembro | 53 | 8 | 61 |
| 2017 Novembro | 20 | 8 | 28 |
| 2017 Outubro | 22 | 9 | 31 |
| 2017 Setembro | 18 | 11 | 29 |
| 2017 Agosto | 19 | 11 | 30 |
| 2017 Julho | 17 | 9 | 26 |
| 2017 Junho | 44 | 16 | 60 |
| 2017 Maio | 26 | 11 | 37 |
| 2017 Abril | 19 | 5 | 24 |
| 2017 Maro | 16 | 10 | 26 |
| 2017 Fevereiro | 18 | 6 | 24 |
| 2017 Janeiro | 21 | 4 | 25 |
| 2016 Dezembro | 15 | 4 | 19 |
| 2016 Novembro | 12 | 3 | 15 |
| 2016 Outubro | 15 | 10 | 25 |
| 2016 Setembro | 12 | 8 | 20 |
| 2016 Agosto | 18 | 1 | 19 |
| 2016 Julho | 9 | 7 | 16 |
| 2016 Junho | 11 | 5 | 16 |
| 2016 Maio | 1 | 14 | 15 |
| 2016 Abril | 16 | 5 | 21 |
| 2016 Maro | 7 | 14 | 21 |
| 2016 Fevereiro | 40 | 36 | 76 |
| 2016 Janeiro | 81 | 65 | 146 |
| 2015 Dezembro | 59 | 50 | 109 |
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