Advertisement

Contribution of Three-Dimensional Transesophageal Echocardiography to Diagnosis and Management of Thrombosis of a St. Jude Mechanical Prosthesis in the Aortic Valve Position

      Prosthetic valve thrombosis (PVT) is a serious complication after cardiac valve replacement and usually requires urgent management with either thrombolysis or surgery.
      • Sun J.C.
      • Davidson M.J.
      • Lamy A.
      • Eikelboom J.W.
      Antithrombotic management of patients with prosthetic heart valves: current evidence and future trends.
      A 38-year-old woman with history of ischemic stroke and multiple valvular surgeries including aortic St. Jude mechanical valve replacement (St. Jude Medical, St. Paul, Minnesota) presented with new-onset dyspnea on exertion. Transthoracic echocardiography and 2-dimensional transesophageal echocardiography (TEE) suggested an abnormally high gradient across the aortic valve (Figure 1) but could not determine the cause of the stenosis (Figure 2, Video 1). Three-dimensional (3D) TEE showed a small mobile thrombus attached to 1 disc of the St. Jude valve, resulting in partially restricted disc mobility (Figure 2, Videos 2 and 3). Also, valvular “pannus” formation was minimal, and the mobility of the other disc of the St. Jude mechanical prosthesis was normal. Thrombectomy with a carbon dioxide high-flow mister blower was chosen to eliminate the thrombus. After elimination of the thrombus and scant fibrous tissue on the underside of the valve, the mobility of the affected disc recovered completely. The gradient across valve was normalized (Figure 1). The patient became asymptomatic and was discharged.
      Figure thumbnail gr1
      Figure 1Mean gradient across the mechanical aortic valve measured using continuous-wave Doppler before (10 mm Hg) (left) and after (59 mm Hg) (middle) thrombus development and after thrombectomy (9 mm Hg) (right).
      Figure thumbnail gr2
      Figure 2Prosthetic valve thrombosis on 2-dimensional TEE (left) and 3D TEE (middle, right).
      PVT can be diagnosed with cine fluoroscopy, transthoracic echocardiography, and TEE. Cine fluoroscopy is effective only at detecting abnormality of leaflet mobility, without providing information on the cause of abnormal leaflet function. Transthoracic echocardiography with Doppler study is used to measure transvalvular pressure gradient but usually has limited accuracy of visualization. TEE is often needed because of its better spatial resolution. However, 2-dimensional TEE has limitations in the assessment of aortic PVT and associated subtle leaflet change, particularly for various mechanical aortic valves.
      • Tong A.T.
      • Roudaut R.
      • Ozkan M.
      • Sagie A.
      • Shahid M.S.
      • Pontes Júnior S.C.
      • Carreras F.
      • Girard S.E.
      • Arnaout S.
      • Stainback R.F.
      • Thadhani R.
      • Zoghbi W.A.
      Transesophageal echocardiography improves risk assessment of thrombolysis of prosthetic valve thrombosis: results of the international PRO-TEE registry.
      Three-dimensional TEE has been increasingly used and has proved to be a valuable technique that offers comprehensible images and comprehensive information of PVT affecting mitral valves.
      • Sugeng L.
      • Shernan S.K.
      • Weinert L.
      • Shook D.
      • Raman J.
      • Jeevanandam V.
      • DuPont F.
      • Fox J.
      • Mor-Avi V.
      • Lang R.M.
      Real-time three-dimensional transesophageal echocardiography in valve disease: comparison with surgical findings and evaluation of prosthetic valves.
      It can determine thrombus size and location, severity of pannus, and mobility of the affected mechanical disc. However, studies on its role in the diagnosis and management of PVT affecting aortic valve are very rare. Our patient had a history of multiple valvular surgeries. In our patient, 3D TEE provided excellent information on PVT features and the functional status of disc mobility. Thus, this case not only provides unique 3D imaging information on aortic PVT but also highlights the novel role of reconstruction using 3D TEE in the diagnosis and management of certain cardiac emergencies.

      Supplementary data

      References

        • Sun J.C.
        • Davidson M.J.
        • Lamy A.
        • Eikelboom J.W.
        Antithrombotic management of patients with prosthetic heart valves: current evidence and future trends.
        Lancet. 2009; 374: 565-576
        • Tong A.T.
        • Roudaut R.
        • Ozkan M.
        • Sagie A.
        • Shahid M.S.
        • Pontes Júnior S.C.
        • Carreras F.
        • Girard S.E.
        • Arnaout S.
        • Stainback R.F.
        • Thadhani R.
        • Zoghbi W.A.
        Transesophageal echocardiography improves risk assessment of thrombolysis of prosthetic valve thrombosis: results of the international PRO-TEE registry.
        J Am Coll Cardiol. 2004; 43: 77-84
        • Sugeng L.
        • Shernan S.K.
        • Weinert L.
        • Shook D.
        • Raman J.
        • Jeevanandam V.
        • DuPont F.
        • Fox J.
        • Mor-Avi V.
        • Lang R.M.
        Real-time three-dimensional transesophageal echocardiography in valve disease: comparison with surgical findings and evaluation of prosthetic valves.
        J Am Soc Echocardiogr. 2008; 21: 1347-1354