Fluoroscopy of Acutely Thrombosed Aortic Valve
A 75-year-old woman with a prior history of aortic valve replacement with a St. Jude Medical mechanical bileaflet prosthesis presented to an outside hospital with an intracranial hemorrhage. Her anticoagulation was reversed with Vitamin K therapy and she was transferred to our center for tertiary neurosurgical care. On day 10 of her admission, she developed new left-sided hemiparesis, and a computed tomography head scan confirmed a middle cerebral artery territory infarct. Physical examination revealed a harsh systolic ejection murmur, and a transthoracic echocardiogram performed to rule out a cardiac source for emboli revealed a severely stenotic mechanical aortic valve with a peak gradient of 146 mm Hg and a mean gradient of 88 mm Hg with moderate aortic insufficiency (Figure 1; online-only Data Supplement Movies I through III). The valve was also assessed by fluoroscopy (online-only Data Supplement Movies IV and V), which showed complete fixation of one leaflet and restricted mobility of the other, with an eccentric jet of aortic regurgitation. A filling defect was visualized around the nonmobile leaflet, highly suggestive of thrombus. Intraoperatively, a large thrombus was visualized around the valve (Figure 2). Fluoroscopy continues to be a simple and accurate method for both diagnosis and follow up of St. Jude valve thrombosis.1 In conjunction with 2-dimensional echocardiography, which can provide hemodynamic assessment of the valve, fluoroscopy is useful for assessing leaflet mobility.2
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/118/22/e705/DC1.