Free floating ball thrombus of left atrium developing late after closed mitral commissurotomy - a case report

Left atrial ball thrombus is very rare entity and it is even rare to find a large free floating ball thrombus of left atrium in a post-operative patient. Thrombus of left atrium usually occurs in atrial fibrillation or in mitral valve stenosis. Here we are presenting a case of large ball thrombus of left atrium in a patient who underwent closed mitral commissurotomy 21 years back. A 50 years old female patient was admitted with history of breathlessness, palpitation and cough of one month duration. She was doing well after mitral valve commissurotomy. Her pre-operative trans-thoracic echocardiography showed a left atrial thrombus and severe mitral stenosis with valvular area of 0.7 cm² and atrial fibrillation. Per-operative trans-oesophageal echocardiography showed a large free floating ball thrombus of left atrium. She underwent removal of left atrial thrombus and mitral valve replacement using Sorin Bicarbon valve.     

Bioprosthetic mitral valve thrombosis less than one year after replacement and an ablative MAZE procedure: a case report

Occurrence of bioprosthetic valve thrombosis less than a year after replacement is very uncommon. Here, we describe a case of a 57 year old male, who presented 10 months after receiving a bioprosthetic mitral valve replacement with a two week history of dyspnea on exertion, worsening orthopnea and decreased exercise tolerance. Echocardiography revealed severe mitral regurgitation (MR), thrombosis of the posterior mitral leaflet, left atrial (LA) mural thrombus and a depressed left ventricular ejection fraction of twenty-five percent. Given severe clot burden and decompensated heart failure (New York Heart Association - NYHA class III) repeat sternotomy was done to replace the bioprosthetic mitral valve and remove LA mural thrombus. MR was resolved postoperatively. This brief report further reviews promoting factors, established guidelines and management strategies of bioprosthetic valve thrombosis.     

Coronary Sinus Approach to Repair an Intracardiac Ventricular Pseudoaneurysm

Abstract A coronary sinus approach using a Gore‐Tex Patch was used to repair an intracardiac left ventricular pseudoaneurysm after a previous bioprosthetic mitral valve replacement. At follow‐up six months after surgery, echocardiography and a computed tomographic scan revealed almost complete obliteration of the pseudoaneurysm cavity. (J Card Surg 2012;27:692‐695)     

Early degeneration of a bioprosthetic mitral valve complicated by a large left atrial thrombus

The authors report the case of a patient with symptomatic early bioprosthetic mitral valve deterioration in the setting of calcium supplementation. This was further complicated by a large left atrial thrombus despite supratherapeutic anticoagulation and a previously oversewn left atrial appendage. As mechanical valves are less predisposed to calcification in comparison with bioprosthetic implants, the patient underwent a mechanical mitral valve replacement in addition to a left atrial thrombectomy.     

Severe stenosis of bioprosthetic valve due to late valve thrombosis

The typical cause of bioprosthetic valve dysfunction over years is calcification of leaflets, pannus formation, or tears due to structural degeneration. Thrombosis is rare as the valves get endothelialized early on, and, hence, anticoagulation is not recommended beyond 6 months after valve replacement. While bioprosthetic valve thrombosis is unusual (0.03% to 0.34%/year), it can be associated with significant mortality and morbidity. Here, we present a case of a middle-aged man with history of bioprosthetic mitral valve who presented with syncopal episode and was referred to us for mitral valve replacement for tentative bioprosthetic valve degeneration and stenosis. However, preoperative work up revealed prosthetic valve thrombosis which was successfully treated with anticoagulation.     

Haemodynamic and echocardiographic characteristics of a stentless allograft mitral prosthesis: an in vitro study

Poor long-term durability and impaired haemodynamic performance are known disadvantages of bioprosthetic heart valves when compared to valve replacement using aortic allografts. A new stentless allograft mitral implant was developed and tested in vitro in a left ventricular model and pulsatile flow system to evaluate hydrodynamic function. Mitral valves were excised from sheep hearts and the mitral annulus reinforced by a strip of ovine pericardium. A patch of expanded polytetrafluoroethylene (ePTFE) was placed above the tips of the remaining papillary muscles. For in vitro evaluation of a total of five valves were investigated in a pulse duplicator. Transvalvular pressure gradients (ΔP) were measured over a flow range corresponding to a cardiac output of 51/min, at a heart rate of 70 beats/min, with a systole accounting for approximately 35% of the cardiac cycle. The systolic ejection period and diastolic filling period in this model were 350 and 510 ms, respectively, and aortic pressure was 120/80 mmHg. The effective orifice area was calculated from measurements of mean pressure drop and root mean square flow. Additionally, valve performance was evaluated by Doppler echocardiography. Results of in vitro studies of a 25 mm stentless allograft mitral implant, which is similar to the valves implanted in a chronic weanling sheep model, revealed a mean(s.d.) ΔP of 2.0(1.6) mmHg (range 1.0 – 4.9 mmHg). The mean calculated effective orifice area was 3.38(0.52) cm² (range 2.5 – 3.8 cm²). Doppler echocardiography showed excellent performance of the mitral valve components and valve competence could be achieved. During the in vitro studies no failure caused by tissue rupture was detected. The results of the in vitro studies revealed data for ΔP and effective orifice area superior to data obtained for standard 25 mm porcine bioprostheses.     

Acute coronary embolism without valve thrombosis in a patient with a prosthetic mitral valve--successful percutaneous coronary intervention: a case report

We present a 44-year-old female patient with anterior myocardial infarction caused by embolization from mitral valve prosthesis due to inadequate anticoagulation. The patient underwent a cardiac catheterization within the 1st hour of arrival. The angiography showed total occlusion of the left anterior descending coronary artery after the second diagonal branch. Percutaneous transluminal coronary angioplasty and stenting were performed, and coronary artery perfusion was restored. The pain disappeared completely immediately after this intervention. Transthoracic echocardiography shortly after this intervention showed normal prosthetic valve function and no thrombus. Transesophageal echocardiography performed 2 days later revealed no thrombus at the prosthetic valve. In conclusion, this case demonstrated that coronary embolism may occur even without prosthetic valve thrombus or dysfunction with suboptimal International Normalized Ratio levels, and can be successfully treated with percutaneous transluminal coronary angioplasty and stenting.     

Accessory mitral valve in an elderly man on maintenance hemodialysis

This report describes a case of accessory mitral valve in an elderly patient on maintenance hemodialysis. Transesophageal echocardiography revealed a mobile sac-like structure with size of 12 × 10 mm², which attached to the left ventricular surface of base of the anterior mitral valve leaflet. Mobile stick-like structure with diameter of 21 mm was extending from this sac-like structure toward the left ventricular outflow tract and had a floating free edge. Peak pressure gradient across the left ventricular outflow tract was 32 mmHg. There were no other congenital cardiac anomalies. No clinical findings suggestive of bacterial or nonbacterial vegetation were seen. Also other possibilities of mobile thrombus or calcification were unlikely. These abnormal structures were diagnosed as accessory mitral valve with rudimentary chordae.     

Mobile biatrial thrombus in a patient with mitral stenosis under heparin infusion

A 58-year-old female patient with complaints of sudden presenting pain and pallor on her left foot was referred to our clinic for urgent embolectomy. On her cardiovascular examination there was an apical grade 2/6 systolic murmur and a grade 2/4 diastolic murmur. The presenting electrocardiography revealed atrial fibrillation with rapid ventricular response. She underwent emergent femoro-popliteal embolectomy. Transthoracic echocardiography showed a mobile 1.4 x 1.7-cm sized left atrial thrombus, mild mitral regurgitation and 9 mmHg mean gradient on mitral valve after embolectomy. Unfractioned (UF) heparin infusion was initiated immediately after surgery. After three days, the control transthoracic echocardiography revealed left atrial thrombus and also a large 'snake-like' thrombus waving in right atrium. The patient underwent biatrial thrombectomy and mitral valve replacement. When she became haemodynamically stable, a bilateral lower limb venous Doppler ultrasonographic study was performed. This study indicated a thrombus formation in the deep veins of the left leg. The origin of the right atrial thrombus was probably a snapped piece of thrombus from the calf deep-veins after the initiation of intravenous UF heparin. In summary, we have reported an extremely rare case of biatrial thrombus in a patient under UF heparin infusion.     

Aortic and mitral valve replacement in an 83-year-old female

An 83-year-old female with aortic and mitral stenosis showed orthopnea. The aortic valve pressure gradient was 139 mm Hg. The mitral valve orifice was 0.92–1.05 cm² and the right ventricular pressure was 70 mmHg. The body surface area of the patient was 1.23 m². Double valve replacement was performed with 16mm CarboMedics pediatric bileaflet valve for the aortic position and 25 mm CarboMedics mitral valve for the mitral position. The patient leads a normal daily life with NYHA class II three years after surgery.     

Immediate effects of mitral valve replacement on left ventricular function and its determinants.

Patients undergoing mitral valve surgery are at risk of left ventricular failure in the immediate post-operative period. In order to understand better the mechanisms of post-operative haemodynamic instability, we used transoesophageal echocardiography to assess the immediate response of the left ventricle to mitral valve replacement for mitral regurgitation or stenosis. A decrease in left ventricular preload, despite adequate filling pressures, was common to both groups and suggests the presence of diastolic dysfunction. A marked impairment in global systolic pump function was observed only in the regurgitation group and correlated with the left ventricular afterload. Transoesophageal echocardiography provides valuable information on the individual changes in left ventricular function and its determinants after mitral valve replacement that are not reflected by haemodynamic measurements.     

A rare case: bioprosthetic tricuspid valvuloplasty dramatically improved hepatic encephalopathy

A 51-year-old woman was diagnosed as severe stenosed tricuspid bioprosthetic valve. She had developed an encephalopathy due to elevated serum ammonia concentration caused by congestive hepatic failure. Re-tricuspid valve replacement was deemed too risky, and balloon bioprosthetic valvuloplasty was instead planned. This procedure was successfully performed using a standard mitral valvuloplasty protocol. The 30-mm INOUE-BALLOON was inflated five times. The mean pressure gradient across the bioprosthetic valve decreased from 7.8 to 3.5 mmHg, and the tricuspid valve orifice area increased from 1.09 to 3.13 cm², without worsening of the tricuspid valve regurgitation. Finally, her hepatic encephalopathy was dramatically improved.     

Left Ventricular Outflow Tract Obstruction After Mitral Valve Replacement

We describe a patient with left ventricular outflow tract obstruction after mitral valve replacement preserving the anterior subvalvular apparatus. Postoperative transesophageal echocardiography demonstrated systolic narrowing of the left ventricular outflow tract by a bulging septum and systolic anterior motion of the preserved anterior mitral leaflet. Septal myectomy and transaortic mitral apparatus resection enabled us to relieve the left ventricular outflow tract obstruction. This suggests that septal hypertrophy might be a relative contraindication to the preservation of the anterior mitral subvalvular apparatus in mitral replacement.     

Chordal preservation improves postoperative ventricular performance following valve replacement for chronic mitral regurgitation

Worsening of left ventricular performance had been recognized after mitral valve replacement for mitral regurgitation. The effects of chordal preservation on ventricular performance after mitral valve replacement have been assessed. Twelve patients with mitral regurgitation were allocated to group A (undergoing mitral valve replacement with chordal preservation), or to group B (undergoing mitral valve replacement with chordal excision). Transoesophageal echocardiography was recorded simultaneously with radial artery and pulmonary capillary wedge pressures. Load was varied by withdrawal of blood from a venous line of cardiopulmonary bypass and/or nitroglycerine bolus. Ventricular performance was assessed by the slope of peak systolic pressure—end-systolic volume relation (Eps), and by the slope of the left ventricular stroke work — end-diastolic volume relationship. Eps significantly decreased immediately after mitral valve replacement (P < 0.02), with no difference among two groups. Eps gradually increased to preoperative levels 10 days after surgery. Pre-load recruitable stroke work also significantly decreased after mitral valve replacement (P = 0.01). The decrease was significantly larger in group B (P < 0.04). These data support the hypothesis that chordal preservation during mitral valve replacement has beneficial effects on left ventricular performance. Copyright © 1996 The International Society for Cardiovascular Surgery.     

A case of bioprosthetic mitral valvular dysfunction due to pannus-formation

A case of bioprosthetic mitral valvular dysfunction accompanied by mitral stenosis due to pannus is reported. A 69-year-old woman, whose mitral valve had been replaced with a Hancock bioprosthetic valve in June 1979, underwent the second mitral valve replacement in September 1988 because of valvular dysfunction. The ring and cusps of this Hancock valve was partially covered with hard and milky white pannus which resulted in mitral stenosis. The tear of cusp was observed at the point of contact with pannus, which resulted in mitral regurgitation. Histologically, pannus was consisted of two-layered structure, fibrin and collagen fiber, which demonstrated this over-growth was based on thrombus. Main causes of bioprosthetic valve dysfunction are calcification and tear of cusps. But, valvular dysfunction due to pannus-formation described in this case has been experienced very rarely.     

Enlarged coronary sinus thrombosis after repair of Ebstein's anomaly

A 58-year-old woman was referred to our hospital with progressively increasing breathlessness. She reported a history of bioprosthetic valve implantation for tricuspid valve replacement and direct closure of an atrial septal defect for Ebstein's anomaly, 31 years before presentation. Transthoracic echocardiography revealed prosthetic valve failure, an enlarged coronary sinus, and severe mitral regurgitation. Computed tomography revealed a giant coronary sinus with thrombosis and persistent left superior vena cava. She underwent successful mitral and tricuspid valve replacement; however, severe hemodynamic deterioration necessitated mechanical ventilatory support with extracorporeal membrane oxygenation.     

Left atrial reverse remodeling improves sinus restoration following mitral valve replacement: A case report

IntroductionMitral stenosis is one of the most common abnormalities in rheumatic heart disease (RHD). These patients often experience atrial fibrillation, due to left atrial dilatation, causing a high risk of thromboembolic events; rhythm or heart rate control are thus important treatment strategies. In patients undergoing surgery, sinus rhythm restoration is not fully understood, and not all surgical patients return to sinus rhythm. We report an adult woman with mitral regurgitation who experienced sinus restoration after mitral valve replacement (MVR) surgery.Case presentationA 44-year-old woman presented with chief complaints of orthopnea and shortness of breath during activity for 2 months. Electrocardiography (ECG) revealed atrial fibrillation with normal ventricular response, and echocardiography showed severe mitral stenosis with Wilkins score of 10 (3-2-3-2), moderate mitral and aortic regurgitation due to RHD, moderate tricuspid regurgitation with probable pulmonary hypertension, normal left ventricular systolic function, ejection fraction of 60.5% (biplane). MVR surgery was performed using a mechanical mitral valve. Postoperative ECG found sinus rhythm and first-degree AV block. Postoperative echocardiography found a decreased left Atrial volume index of 70.8 mL/m², indicating further remodeling of the patient's heart.ConclusionSinus restoration sometimes occurs in patients after MVR. The correction procedure causes minimal anatomical changes, particularly the loss of non-conductive and pathological tissue, followed by hemodynamic changes that eventually lead to the left atrial reverse remodeling mechanism.     

Management of Prosthetic Valves during Ventricular Assist Device Implantation

Abstract Background: An increasing number of patients requiring ventricular assist devices (VAD) have had previous valvular corrections, including valve repair and valve replacement with mechanical or bioprosthetic valves. The operative and peri‐operative management of these patients has been varied. Methods: A retrospective study of VADs between January 1994 and June 2008 revealed 10 patients with previous prosthetic valves requiring management during and after VAD placement. Three patients were supported postcardiotomy after valve surgery. Two patients were supported due to cardiogenic shock postoperatively. Four patients were supported as a bridge to transplantation. One patient was supported as a destination therapy (DT). Results: The mitral, valve was left untreated during VAD implantation regardless of valve repair or replacement. For aortic valves, the mechanical aortic valve was replaced with tissue valve in two patients and left untreated in one case. One patient had tricuspid valve repair previously and was left untouched. All patients with prosthetic valves in aortic, mitral and tricuspid position during VAD support received anticoagulation therapy. There were four deaths, and four went on to transplantation. One patient was weaned from VAD and discharged from the hospital. One patient received HeartMate I as DT. The most common causes of death were multisystem organ failure (MSOF) and sepsis. One patient had a thromboembolic event. Conclusions: The survival rate of 60% is encouraging when compared to overall survival rates. The most common cause of death was MSOF. Patients with prosthetic valves may be safely managed during VAD support. (J Card Surg 2010;25:601‐605)     

人工心脏瓣膜置换术后心内血栓形成危险因素的一年随访研究

目的 探讨人工心脏瓣膜置换术后心内血栓形成的危险因素.方法 回顾性分析2005年1月至2009年4月690例瓣膜置换手术者中在住院期间或1年内随访发现心内血栓形成的29例患者,其中男性11例,女性18例;年龄12～70岁,平均48岁.单因素和Logistic回归多因素分析影响瓣膜置换术后心内血栓形成的危险因素.结果 单因素分析显示,21个独立因素中共有7个因素即生物瓣置换、阿司匹林抗凝、二尖瓣置换、心房颤动、术前左心房内径、术后左心房内径、术后纤维蛋白原水平与术后心内血栓形成有关(P<0.05).多因素分析显示,二尖瓣置换(OR=9.815,P<0.05)、心房颤动(OR=5.267,P<0.05)、术前左心房增大(OR=4.529,P<0.05)是术后心内血栓形成的独立危险因素.结论 人工瓣膜置换术后心内血栓形成与二尖瓣置换、心房颤动、术前左心房增大有相关性.应重视生物瓣置换术后的抗凝.     

Transthoracic echocardiographic assessment of haemodynamics in severe pre‐eclampsia and HIV in South Africa

Haemodynamic and cardiac structural changes in severe pre‐eclampsia and in pregnant women with human immunodeficiency virus (HIV) infection have not been clearly established. We performed transthoracic echocardiography on 105 women. Women with pre‐eclampsia demonstrated (mean (SD), untreated vs treated) preserved fractional shortening (40 (7.1)% vs 41 (8.6)%), a non‐dilated left ventricle (4.5 (0.49) cm vs 4.4 (0.44) cm), increased mitral valve E/septal e′ (10.5 (3.3) vs 10.6 (2.8)), and preserved tricuspid annular plane systolic exertion (2.6 (0.36) cm vs 2.4 (0.51) cm). Women with HIV infection demonstrated (mean (SD), HIV‐positive vs healthy) a reduced cardiac index (2.8 (0.64) ml.min^?1.m^?2 vs 3.1 (0.7) ml.min^?1.m^?2, p = 0.029), reduced septal s′ tissue Doppler velocity (8.5 (1.5) cm.s^?1 vs 9.3 (1.7) cm.s^?1, p = 0.042), increased left ventricular end‐diastolic area (7.6 (2.1) cm² vs 6.3 (1.7) cm²_, p = 0.004), and reduced right ventricular s′ and e′ velocity (s′ velocity 14.7 (3.1) cm.s^?1 vs 7.0 (2.9) cm.s^?1 p = 0.001, e′ velocity 16.3 (4.1) cm.s^?1 vs 18.7 (3.4) cm.s^?1, p = 0.013). The mitral value E/septal e′ was > 8 in 39% of patients with HIV. Fractional shortening (< 28%) was reduced in 10% of healthy women, and mitral valve E/septal e′ ratios were > 8 in 38% of that group. Women with pre‐eclampsia demonstrated preserved systolic function, with diastolic dysfunction. Women with HIV demonstrated reduced left and right ventricular systolic function, with increased ventricular dilatation.