Prosthetic mitral valve thrombosis,malfunction, and paroxysmal mitral regurgitation

Intermittent dysfunction of mechanical mitral valve prosthesis is an uncommon condition. It carries serious clinical implications if unrecognized. Here, we present a case of a 28‐year‐old female with a history of rheumatic multivalvular disease, for which she had undergone double valve replacement and tricuspid annuloplasty. Six months later, she presented with heart failure. Clinical examination revealed intermittent loss of closing clicks followed by a pansystolic murmur at the apex, suggestive of mitral prosthetic valve dysfunction. We highlight the echocardiographic findings of paroxysmal mitral valvular regurgitation secondary to prosthetic valve malfunction secondary to prosthetic valve thrombosis.     

Current status of the Beall, Bjork-Shiley, Braunwald-Cutter, Lillehei-Kaster and Smeloff-Cutter cardiac valve prostheses

The Starr-Edwards ball valve prosthesis is generally the standard by which other cardiac valve substitutes are compared. This report reviews information pertaining to several prostheses—the Beall mitral valve and the Bjork-Shiley, Braunwald-Cutter, Lillehei-Kaster and Smeloff-Cutter aortic and mitral valves—considered by some to have specific advantages over the Starr-Edwards valves.

Hospital and late mortality rates after valve replacement are comparable for the four aortic valve prostheses reviewed and depend more on patient selection than on the specific prosthesis utilized. Extensive clinical experience with the Bjork-Shiley aortic valve indicates that this prosthesis offers hemodynamic advantages over ball valve prostheses, especially in patients with a small aortic root. Clinical experience with the Lillehei-Kaster pivoting disc prosthesis has been less extensive, but this model provides theoretical hemodynamic advantages similar to those of the Bjork-Shiley aortic valve prosthesis. Problems associated with cloth wear and the unexpectedly slow rate, in man, of tissue ingrowth into the fabric of the Braunwald-Cutter aortic valve prosthesis have been discouraging, although this prosthesis has been associated with a very low thromboembolic rate in patients receiving anticoagulant therapy. The Smeloff-Cutter aortic prosthesis is hemodynamically similar to the Starr-Edwards prosthesis and has been proved to be a reliable and durable aortic valve substitute over the past several years.

Mortality after mitral valve replacement is also largely influenced by factors other than prosthetic valve design. On the basis of postoperative data, the five mitral valve prostheses reviewed do not appear to have substantial hemodynamic differences. For patients with a small left ventricular cavity the low profile prostheses, such as the Beall, Bjork-Shiley and Lillehei-Kaster, may be advantageous.

Most available evidence indicates that patients receiving aortic or mitral valve prostheses should be given anticoagulant therapy postoperatively.     

Primary results with the new Hall-Kaster disc valve prosthesis in mitral position.

The Hall-Kaster central flow prosthetic heart valve was introduced in 1977 in an attempt to improve the hemodynamics of the disc valve prostheses. Towards this accomplishment, innovations in the tilting axis, the disc guidance mechanisms, and disc translational freedom cooperate to improve flow through both orifice segments of the open valve. The present study reports on the primary clinical and hemodynamic findings in the first 20 patients (mean age 57.6 years) with isolated mitral valvular disease, examined 3--4 months after insertion of the Hall-Kaster disc valve prosthesis. The hemodynamic findings displayed low gradients and high calculated valve areas (5). At rest, the mean diastolic pressure gradient across the smallest prosthesis used (O.D. 27) averaged 3.0 mmHg, vs. 2.6 mmHg across the largest valve sizes (O.D. 29--31). Calculated valve area was on an average 3.08 cm2 for the smaller valve, and 3.47 cm2 for the larger valves, which corresponded to an utilization of 81% and 77% of the orifice area measured in vitro. A comparison with earlier studies of mean diastolic mitral gradients with different mitral prostheses indicates that the Hall-Kaster disc valve represents an improvement towards a hemodynamically more efficient prosthesis for mitral valve replacement.     

Periodic intermittent electromechanical dissociation: Hemodynamic correlate of a malfunctioning mechanical prosthetic valve

We describe a patient who developed the unusual haemodynamic phenomenon of periodic intermittent electromechanical dissociation during regular sinus tachycardia about 20 hours after mitral valve replacement with a tilting disc mechanical prosthesis. Echo-cardiographic confirmation allowed prompt and life saving corrective surgery for a stuck prosthetic valve disc. © 1996 Wiley-Liss, Inc.     

Thrombosis and endocarditis in prosthetic heart valves, a case report.

The authors report the case of a 49-year-old female with a history of rheumatic valvular heart disease who underwent valve surgery in 1997, with implantation of St. Jude prosthetic valves in aortic and mitral position. She was asymptomatic until the end of July 2001, when she was admitted to Garcia de Orta Hospital emergency unit because of heart failure, fever and suspicion of endocarditis. Cardiologic evaluation was requested and the transthoracic (TTE) and transesophageal (TEE) echocardiograms revealed vegetations on the prosthetic mitral valve. Blood cultures were negative. She started empiric antibiotic therapy and the clinical course stabilized in the first week. After ten days of medical therapy her symptoms became worse and TTE and TEE were repeated. TTE showed significant left ventricular-aortic gradient, suggesting aortic valve obstruction. Decreased left ventricular function was now present with hypokinesia in the anterior descending coronary artery territory. In the TEE, a large thrombotic process on the mitral prosthesis valve was seen, with a prosthesis disk blocked. There were similar findings in the aortic valve. Cardiac fluoroscopic images were obtained at the mitral and aortic position confirming the TEE report. The coronary angiogram was normal. Promptly transferred to a cardiac surgery center, the patient underwent aortic and mitral prosthetic valve replacement. The intraoperative findings were compatible with those from echocardiography and cardiac fluoroscopy.     

Stenosis of a mechanical mitral prosthetic valve in a patient with systemic lupus erythematosus

A young woman with systemic lupus erythematosus (SLE) developed progressive heart failure several years after mitral valve replacement with a Bj?rk-Shiley prosthesis for treating mitral stenosis due to Libman-Sacks endocarditis. She was admitted to the hospital with pulmonary oedema. Transoesophageal echocardiography revealed stenosis of the mitral prosthesis, which was covered by fibrous tissue. Replacement of the prosthesis was done but the patient died from cerebral haemorrhage three days later. Although three cases of prosthetic valve dysfunction in SLE have been documented so far, this is to our knowledge the first report of a SLE recurrence on a tilting disc mechanical valve.     

Acute thrombosis of Sorin tilting disc mitral prostheses

We observed four cases of prosthetic thrombosis in 77 patients who had had a tilting disc valve (Sorin model) inserted in the mitral position. In all cases, the clinical findings on admission consisted of congestive heart failure, absence of prosthetic closing click and mitral regurgitation murmur. M-mode and cross-sectional echocardiography were invariably diagnostic. Surgery was performed without delay and consisted of thrombectomy in one case and valve replacement with porcine xenograft in three. Examination of the explanted prostheses disclosed fibrous tissue overgrowth surrounding the valvular ring, as well as thrombotic vegetations on the ventricular and atrial sides. The disc appeared blocked in a semiopening position at an angle of 45 degrees. Our experience suggests that the thrombosis is secondary to disc malfunction itself produced by periannular tissue growth. It is related to the porosity of the fabric which surrounds the metal ring, the valve design and its orientation. Correct anticoagulation therapy, performed in all cases, had no significant effect on tissue overgrowth. The high postoperative mortality rate depended on the severity of the preoperative clinical condition of the patients.     

Valve replacement with Macchi prosthesis]

OBJECTIVE: to evaluate the performance of a new ball valve prosthesis. DESIGN: set up of two groups of patients who underwent mitral valve replacement with two different prosthesis: the Macchi prosthesis under evaluation and the well known Starr-Edwards model prosthesis. The chi-square test was used to compare the results. PATIENTS: Patients referred for valvular surgery. INTERVENTIONS: One group of 98 consecutive patients who underwent isolated mitral valve replacement with a Macchi prosthesis from January 1984 to June 30 1986 was compared to a matched group of 49 patients who received a Starr-Edwards prosthesis in the same period of time. Follow-up data were available from 99% patients in the Macchi group 96% in the Starr-Edwards group, with a mean follow-up time of 35.2 (2-57) and 42.9 (4-62) months, respectively. RESULTS: There was no statistical difference in the incidence per 100 patients--month of prosthetic complications--thromboembolism, hemorrhagic events, prosthetic endocarditis, reoperation and mechanical failure. CONCLUSIONS: In our experience and with the available follow-up data the Macchi prosthesis is a good cost effective option when there is indication for a ball valve prosthesis.     

Unsuspected amyloidosis and cardiac arrest following mitral valve replacement

We performed an autopsy on a 58-year-old female with previously unsuspected cardiac amyloidosis. One day prior to expiration the patient underwent a mitral valve replacement with a Bjork-Shiley prosthesis for mitral valve regurgitation. The valvular defect along with the massive myocardial amyloidosis which created a restrictive cardiomyopathy, were the etiology of the patient's poor cardiac output and subsequent demise.     

Thrombosis of mitral valve prosthesis presenting as abdominal pain.

A 67-year-old woman presented with abdominal pain, anemia, and leukocytosis. Five years previously, the patient had undergone mitral valve replacement with a St. Jude bileaflet mechanical prosthesis. After her admission, echocardiography confirmed an immobile leaflet of the prosthetic valve. At urgent surgery, thrombosis and pannus, obstructing the disc, were found, and the mechanical valve was replaced with a bioprosthesis. The incidence of mitral valve thrombosis is low, ranging from 0.1% to 5.7% per patient per year. Patients who receive inadequate anticoagulation, particularly with valve prostheses in the mitral position, have an increased risk for thrombus or pannus formation. Presentation varies, from symptoms of congestive heart failure or systemic embolization, to fever or no symptoms. New or worsening symptoms in a patient with a prosthetic heart valve should raise concerns about prosthetic dysfunction. Aggressive investigation and, if indicated, urgent or emergency surgery for treatment can be lifesaving.     

Thrombolytic therapy for a thrombosed bjork-shiley tricuspid valve prosthesis

Summary: A 67-year-old man in whom mitral and tricuspid Bjork-Shiley tilting disc prostheses had been implanted 68 months previously presented with thrombotic obstruction of his tricuspid prosthesis. Initial cardiac catheterization demonstrated a significant transprosthetic tricuspid diastolic gradient (9.5 mmHg) with a calculated prosthetic valve orifice area (0.62 cm²) indicating a critical degree of stenosis. The resting cardiac index was markedly reduced (1.5 l/m²/min). Following an intravenous infusion of streptokinase for 66 hours, repeat cardiac catheterization revealed a 50% reduction in transprosthetic diastolic gradient across the tricuspid valve (4.7 mmHg), a greater than fourfold increase in prosthetic valve orifice area (2.87 cm²) with a normal resting cardiac index (3.1 1/m²/min).     

Cardiac pathology after valve replacement with a tilting disc prosthesis (Björk-Shiley type): A study of 46 necropsy patients and 49 Björk-Shiley prostheses

Clinical and necropsy observations are described in 46 patients who had one or more cardiac valves replaced with a tilting disc prosthesis of the Björk-Shiley type, and these observations are compared with earlier observations in patients with caged ball, caged disc and trileaflet prostheses. In contrast with its frequent occurrence in patients studied earlier with peripheral flow prostheses, either caged ball or caged disc, prosthetic dysfunction from prosthetic disproportion (too small a ventricular cavity or aortic root to freely accommodate the prosthesis) was observed in only 2 of the 46 patients with the semicentral flow Björk-Shiley prosthesis. Significant trauma to erythrocytes, as determined by the presence of renal hemosiderosis, occurred in only 1 of 11 patients who died late after Björk-Shiley valve replacement; it occurred more frequently and with far greater severity in patients who died late after valve replacement with a caged ball or caged disc prosthesis. Prosthetic thrombi may be less frequent after valve replacement with a tilting disc than after replacement with a caged ball or caged disc. They occurred in 7 of 13 patients who died late after Björk-Shiley valve replacement, but 3 of the 7 patients had infective prosthetic endocarditis, and of the remaining 4, only one had been receiving warfarin sodium. In contrast, prosthetic thrombi were observed in 81 and 88 percent, respectively, of 112 patients who died late after valve replacement with a caged ball or caged disc prosthesis, and most of the 112 patients had received anticoagulant therapy. Although the implantation periods were relatively short (3 to 30 months, average 11), prosthetic wear or variance of the tilting disc prosthesis did not occur in any of the 13 patients who died late.

Although the tilting disc (Björk-Shiley) prosthesis is prone to clot (and therefore patients with it require long-term anticoagulation), the device is not intrinsically stenotic or significantly incompetent, it is only minimally traumatic to erythrocytes and, at this time, there is no evidence of prosthetic degeneration or variance.     

Traumatic cardiac hemolytic anemia: a late complication of a Starr-Edwards mitral valve prosthesis.

Severe, traumatic, cardiac, hemolytic anemia developed in a patient nine years after mitral valve replacement with a Starr-Edwards model 6120 prosthesis. Cardiac catheterization failed to demonstrate a perivalvular leak or prosthetic malfunction. Transfusion on two occasions resulted in accelerated hemolysis and failed to maintain an appreciable elevation of the hemoglobin level. At operation, a perivalvular leak was found. Replacement of the valve led to complete resolution of the hemolytic problem. The case demonstrates that cardiac hemolysis may be a good indicator of valve dysfunction.     

Late thrombosis of the aortic Bjork-Shiley prosthesis. Its clinical recognition and management.

Seven cases of massive thrombosis of an aortic Bjork-Shiley prosthesis were encountered among 433 valvular implants. Four patients died before treatment could be instituted, and three underwent repeat surgery successfully. Anticoagulation therapy was probably well maintained in four, and poorly maintained in three patients. These cases illustrated the need for a high index of suspicion and prompt recognition of this complication in patients with Bjork-Shiley prostheses. The diagnosis of massive thrombosis should be suspected with the rapid onset of (1) signs of congestive heart failure, (2) absence or attenuation of valvular clicks, (3) aortic regurgitation, or (4) hemolytic anemia. Salvage of these patients requires emergency replacement of the thrombosed prosthesis or removal of the thrombus.     

Do All Hemolytic Anemias That Occur After Mitral Valve Repair Require Surgical Treatment?

We report on a 29-year-old woman with severe hemolytic anemia following mitral valve annuloplasty. Although hemolysis due to mechanical prosthetic mitral valve is well recognized, hemolytic anemia associated with mitral valve repair is an uncommon condition. Reoperation may be considered if the patient has serious and persistent anemia. Although valve replacement is suggested to be a unique intervention, it may not be the solution every time because of mechanical effects. Various mechanisms of hemolysis related to mitral valve repair were suggested, but sufficient and precise data is not available. In this case, we tried to emphasize whether all hemolytic anemias that occur after mitral valve repair require surgical treatment.     

An emergency physician's guide to prosthetic heart valves: identification and hemodynamic function

We describe methods for identifying the type and size of seven commonly used prosthetic heart valves and how these features influence the hemodynamics of flow through the valve. The four mechanical heart valves reviewed are Starr-Edwards silicone rubber ball valves (Models 1200/1260 aortic and 6120 mitral valves), Bjork-Shiley tilting disc valves (60 degrees standard spherical model and the 60 degrees convexo-concave model), Medtronic-Hall (Hall-Kaster) tilting disc valve, and St Jude Medical bileaflet valve. The three bioprostheses reviewed are Hancock porcine valve, Carpentier-Edwards porcine valve, and Ionescu-Shiley bovine pericardial valve. These valves were chosen because of their past or present popularity and therefore are the ones most apt to be implanted in patients seen in the emergency department.     

Doppler and two-dimensional echocardiographic diagnosis of Bj?rk-Shiley prosthetic valve malfunction: importance of interventricular septal motion and the timing of onset of valve flow

In a 69 year old woman with a "sticking" Bj?rk-Shiley mitral prosthesis, the diagnosis was suggested by both the two-dimensional and the Doppler ultrasound examinations. In particular, the findings of early diastolic paradoxic septal motion, intermittent delayed opening of the prosthetic disc and variable timing of the onset of mitral valve inflow were believed to be diagnostic of a sticking tilting disc prosthesis.     

Diagnosis of prosthetic mitral valve malfunction with combined echo-phonocardiography.

Fifty-three patients were studied with combined echo-phonocardiography or phonocardiography alone following prosthetic valve replacement. In sixteen of these patients, clinical deterioration developed, and all subsequently underwent cardiac catheterization and/or surgery. Two patients came to autopsy. Included in this group of sixteen patients were five with obstructed prosthesis, six with paravalvular regurgitation, and five with left ventricular dysfunction. Measurements were made of the time interval from the aortic valve closure sound to the peak opening of the mitral prosthesis determined echocardiographically or to the mitral prosthetic opening click (A2-MVO). Echocardiographic studies of left ventricular wall motion were also performed. The A2-MVO interval was significantly shortened (P less than 0.01) with prosthetic valve obstruction (.05 +/- .02 sec) and paravalvular regurgitation (.05 +/- .01 sec) compared with normally functioning prostheses (Starr-Edwards ball valves .10 +/- .02 sec, Lillehei-Kaster tilting disc prostheses .09 +/- .01 sec). Shortening of this interval was not specific for these conditions because it was sometimes shortened with left ventricular dysfunction. Echocardiographic studies of left ventricular wall motion were helpful in distinguishing among prosthetic valve obstruction, paravalvular regurgitation and left ventricular dysfunction. The combined echo-phonocardiographic technique was especially helpful in detecting malfunction of tilting disc prostheses, because the technique enables measurement of the A2-MVO interval in the absence of an audible opening click.     

Strut-fracture of a Bjork--Shiley tilting disc valve diagnosed by echocardiography--A case report

A 40-year-old man with Bjork-Shiley valves implanted in theaortic and mitral positions nine months previously presentedwith central chest pain. Shortly after admission he developedclinical features consistent with left ventricular failure.Fracture of the mitral prosthesis was diagnosed by echocardiography.At emergency operation the outlet strut of the mitral valvewas found to be fractured and the disc was in the left ventricle.The patient survived valve re-placement and is in good healthfour years later.     

Intermittent mitral regurgitation: an indicator of severe Beall valve dysfunction

The Teflon disc of Beall valves is subject to extraordinary wear and tear. Clinical evidence of valvular dysfunction is critical in following patients who have implanted Beall valves. We describe 4 patients with the interesting auscultatory finding of intermittent mitral regurgitation. Each of these patients demonstrated severe wear of the Teflon disc with abnormal intermittent disc tilting noted at cardiac catheterization. Intermittent mitral regurgitation in patients with Beall valves in the mitral position heralds severe valvular dysfunction and should prompt urgent cardiac catheterization and valve replacement.