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(Circulation. 2008;117:257-260.)
© 2008 American Heart Association, Inc.

Images in Cardiovascular Medicine

Intermittent Trapping of a Tilting-Disc Mitral Prosthesis

Iván J. Núñez-Gil, MD; José A. De Agustín, MD; Juan C. García-Rubira, MD, PhD; Leopoldo Perez de Isla, MD, PhD

From the Cardiology Department, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain.

Correspondence to Dr Iván Javier Núñez-Gil, Calle Prof Martin Lagos S/N, 28040 Madrid, Spain. E-mail ibnsky{at}yahoo.es

A 57-year-old woman presented to our emergency room complaining of palpitations and crescent dyspnea. She had carried a tilting-disk mitral valve prosthesis since 1985.

The ECG showed atrial tachycardia with 2:1 conduction (Figure 1). Her arterial pressure was 75/50 mm Hg, but signs of hypoperfusion were not apparent. On heart auscultation, prosthetic clicks were erratically audible. Transthoracic and transesophageal echocardiograms were performed (Figure 2A). They demonstrated that the valve opened once between 3 and 4 beats (Movies I and II). This point was confirmed by means of an invasive arterial pressure line showing alternant effective beats (Figure 1). After sinus rhythm was restarted with one 150-J shock, high gradients and velocities remained. After a thorough Doppler search, a high-pressure half-time of the ineffective beats was shown (Figure 2B).

View larger version (49K): [in this window] [in a new window]   Figure 1. ECG presenting an atrial tachycardia at 115 bpm and the invasive arterial line (below) showing pulse alternance.

View larger version (38K): [in this window] [in a new window]   Figure 2. A, Doppler continuous mode of the mitral inflow showing a high mitral valve gradient (medium, 23.5 mm Hg; normal, 4.1±1.6 mm Hg) and high velocity (3.37 m/s; normal, 1.7±0.3 m/s).1 B, Doppler continuous mode of the mitral inflow with a first curve showing an increased high-pressure half-time (left) and a second curve showing the opening of the prosthesis (high-pressure half-time normal), corresponding to an ineffective and an effective beat, respectively.

Cine fluoroscopy is superior to echocardiography in identifying disk motion, whereas Doppler study allows the measurement of gradients and areas.^1,2 Cine fluoroscopy and transthoracic echocardiograms are quick, effective, and complementary diagnostic tools to diagnose prosthetic valve thrombosis in most patients, but transesophageal echocardiogram remains the gold standard technique in selected cases.³

The patient underwent immediate urgent surgery (Figure 3), and the tilting-disk prosthesis was replaced by a bileaflet one. The surgeon reported the presence of a large amount of pannus in the ventricular side of the prosthetic valve, which explained the intermittent trapping of the disk. Patient outcome was uneventful. In-hospital stay was 8 days.

View larger version (122K): [in this window] [in a new window]   Figure 3. Intraoperative image. Tilting mitral valve is shown.

Trapping and acute immobilization of a tilting-disk heart valve are very uncommon complications that require urgent surgery. Other described materials that can cause disk trapping are thrombus, strands of chordal tissue, suture material, and ventricular myocardium.⁴

	Disclosures

Top Disclosures References

 
None.

	Footnotes

 
The online Data Supplement, consisting of movies, can be found with this article at http://circ.ahajournals.org/cgi/content/full/117/2/257/DC1.

	References

Top Disclosures References

 
1. Prosthetic valve evaluation. In: Oh JK, Sewards JB, Jamil A, Eds. The Echo Manual. 3rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 2006: 226–242.

2. Cianciulli TE, Lax JA, Beck MA, Cerruti FE, Gigena GE, Saccheri MC, Fernández E, Dorelle AN, Leguizamón JH, Prezioso HA. Cinefluoroscopic assessment of mechanical disc prostheses: its value as a complementary method to echocardiography. J Heart Valve Dis. 2005; 14: 664–673.[Medline] [Order article via Infotrieve]

3. Montorsi P, De Bernardi F, Muratori M, Cavoretto D, Pepi M. Role of cine-fluoroscopy, transthoracic, and transesophageal echocardiography in patients with suspected prosthetic heart valve thrombosis. Am J Cardiol. 2000; 85: 58–64.[CrossRef][Medline] [Order article via Infotrieve]

4. Williams DB, Pluth JR, Orszulak TA. Extrinsic obstruction of the Björk-Shiley valve in the mitral position. Ann Thorac Surg. 1981; 32: 58–62.[Abstract]

This Article Extract Full Text (PDF) Data Supplement Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Núñez-Gil, I. J. Articles by Perez de Isla, L. Search for Related Content PubMed PubMed Citation Articles by Núñez-Gil, I. J. Articles by Perez de Isla, L. Related Collections Other heart failure Congestive Valvular heart disease Echocardiography CV surgery: valvular disease Arrhythmias, clinical electrophysiology, drugs