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Use of Computed Tomography to Distinguish Thrombus from Pannus on a Bioprosthetic Aortic Valve.

ABSTRACT: Bioprosthetic valve thrombosis was previously considered to be a relatively rare complication of surgical or transcatheter bioprosthetic valve replacement. Although echocardiograms can reliably show the characteristic findings of prosthetic valve stenosis, differentiating between thrombus formation and pannus overgrowth as the underlying cause of prosthetic valve dysfunction can be challenging. We present the case of a 75-year-old man who underwent transthoracic Doppler echocardiography in the presence of an elevated valvular gradient 2 years after his aortic valve had been surgically replaced with a bioprosthesis. The echocardiographic findings suggested prosthetic valve stenosis. Cardiac computed tomography, performed to distinguish between thrombus formation and pannus overgrowth, revealed hypoattenuated leaflet thickening and reduced leaflet mobility, which suggested thrombus. After the patient took oral anticoagulants for 3 months, images showed complete resolution of the previous abnormalities, thus confirming the diagnosis of bioprosthetic valve thrombosis. We found cardiac computed tomography valuable when evaluating our patient who had an elevated prosthetic valve gradient.

SUBMITTER: Kealhofer JV

PROVIDER: S-EPMC6827474 | biostudies-literature | 2019 Jun

REPOSITORIES: biostudies-literature

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Use of Computed Tomography to Distinguish Thrombus from Pannus on a Bioprosthetic Aortic Valve.

Kealhofer Jessica V JV Markowitz Jeremy S JS Nijjar Prabhjot S PS

Texas Heart Institute journal 20190601 3

Bioprosthetic valve thrombosis was previously considered to be a relatively rare complication of surgical or transcatheter bioprosthetic valve replacement. Although echocardiograms can reliably show the characteristic findings of prosthetic valve stenosis, differentiating between thrombus formation and pannus overgrowth as the underlying cause of prosthetic valve dysfunction can be challenging. We present the case of a 75-year-old man who underwent transthoracic Doppler echocardiography in the p ...[more]

PMID: 31708708

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Project description:BackgroundSubaortic pannus formation complicates bioprosthetic aortic valve (AV) replacement. We report an extreme case in a continuous-flow left ventricular assist device (LVAD) patient.Case summaryA 49-year-old Caucasian female with dilated cardiomyopathy was bridged to transplant with a HeartWare Ventricular Assist Device (Medtronic). Duration of support was prolonged, 6 years & 7 months, due to allosensitization requiring desensitization. Pump thrombosis occurred 2 years & 4 months post-LVAD requiring alteplase thrombolysis. The patient underwent bioprosthetic AV replacement 3 years & 10 months post-LVAD for symptomatic aortic incompetence. Transthoracic echocardiography (TTE) performed 1 year and 2 years post-bioprosthetic AV replacement repeatedly demonstrated an AV closed during all cardiac cycles without incompetence and nil flow through the left ventricular outflow tract (LVOT). Following transplant, analysis of explanted heart revealed a fused AV. A pannus adherent to the underside of the AV had formed across the entire AV outlet, with complete obliteration of LVOT. This subaortic pannus was not visualized on previous TTE. Histologically, the pannus consisted of hypocellular fibrous tissue with chronic inflammatory cells, spindle histiocytes, and myofibroblasts scattered throughout the loose fibromyxoid stroma, the latter highlighted on CD68 immunohistochemical stain (IHC). Partial endothelialization on the pannus surface was highlighted on ERG and CD31 IHC. Neither calcification nor signs of acute inflammation were noted. In contrast to previous cases, there was no evidence of associated thrombus macroscopically or microscopically.DiscussionProlonged LVAD support may facilitate subaortic pannus following bioprosthetic AV replacement due to AV closure and altered transvalvular flow. Due to the parallel LVAD circulation, subaortic pannus may develop asymptomatically, without haemodynamic compromise, allowing progression to total LVOT obstruction. This requires consideration prior to LVAD explantation in bridge-to-recovery patients.

Dataset Information

Use of Computed Tomography to Distinguish Thrombus from Pannus on a Bioprosthetic Aortic Valve.

Publications

Use of Computed Tomography to Distinguish Thrombus from Pannus on a Bioprosthetic Aortic Valve.

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