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- Received March 22, 2010
- Accepted April 1, 2010
- Published online January 4, 2011.
A 62-year-old man, with a Medtronic Hall tilting-disk aortic valve (Medtronic, Minneapolis, Minnesota) inserted 12 years earlier, presented with a 3-day history of progressive dyspnea. A peak aortic gradient of 50 mm Hg existed 12 months before the current presentation, likely representing pannus formation. Recently, the patient had undergone inguinal hernia repair; warfarin was ceased without bridging therapy.
Examination revealed a thrill and loud ejection systolic murmur over the aortic area, reduced carotid upstroke, and inspiratory crackles. There was variable absence of the prosthetic second heart sound on auscultation, confirmed on phonography (A). A transthoracic echocardiogram demonstrated a peak gradient of 105 mm Hg. Fluoroscopy revealed an obstruction to the complete opening of the prosthesis with intermittent nonclosure (Online Video 1) and a lesion on the ventricular side of the prosthetic valve (Online Video 1, arrow). The intermittent obstruction to closure was associated with aortic incompetence (color Doppler) (B) and a significant fall in systolic blood pressure measured concurrently in the ascending aorta (C).
Urgent aortic valve replacement confirmed the presence of a large thrombus on the inflow of the prosthesis, impacting valve motion, with extensive pannus formation (D). Combining clinical examination, phonography, fluoroscopy, and echocardiography is valuable when pannus with thrombus formation is suspected. Perioperative bridging therapy should be considered even in low-risk prosthetic valves.
- Received March 22, 2010.
- Accepted April 1, 2010.
- American College of Cardiology Foundation