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Pannus appeared to originate in the neointima in the periannulus of the left ventricular septum. The structure of the pannus consisted of myofibroblasts and an extracellular matrix such as collagen fiber. The pannus formation after prosthetic valve replacement may be associated with a process of periannular tissue healing via the expression of transforming growth factor-beta.

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Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp ortic valve replacement (AVR) with a prosthetic cardiac valve is an established therapeutic approach for significant aortic valve disease. Despite recent advances in prosthetic valve technology and anticoagulant therapy, prosthetic valve obstruction (PVO) due to thrombus or pannus is a serious and occasionally fatal valve-related complication. 1-8 The incidence of PVO due to pannus is generally estimated to be 0.1-0.6% per patient-year in the aortic position, 1,2,9 but obstruction of an aortic prosthetic valve caused by pannus is higher in frequency than previously reported and is detected even in asymptomatic patients. 2,4,10 Echocardiography and cineradiography are commonly used diagnostic techniques for PVO, 2,4,11 but identification of the exact cause of PVO, such as thrombus or pannus, is difficult. We have previously reported the usefulness of electrocardiographically (ECG)-gated multidetector-row computed tomography (MDCT) for detecting subprosthetic overgrown pannus in the aortic position in several cases. [12][13][14] In this study, we evaluated the role of MDCT in diagnosing PVO and the utility of MDCT in identifying the underlying causes of PVO in the aortic position. Methods PatientsThe current study was approved by the Ethics Committee of Kurume University, and written informed consent was obtained from all participating patients after they were notified of the risks of radiation exposure and complications due to use of contrast medium.

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A 64-year-old woman underwent aortic valve replacement with a 21-mm Advancing The Standard (ATS) open-pivot mechanical heart valve for bicuspid aortic valve stenosis. In addition to the appearance of a new cardiac murmur, echocardiography performed 3 years after surgery showed a high pressure gradient across the ATS valve and a reduction in the valve orifice area. Cineradiography of the valve revealed restricted leaflet opening. Subsequent multidetector-row computed tomography clearly demonstrated pannus overgrowth on the inflow aspect of the ATS valve. During a repeat operation, subvalvular overgrown pannus was confirmed and the ATS valve was replaced with a bioprosthetic valve. This is the first reported case of prosthetic valve dysfunction resulting from pannus formation in a patient with an ATS valve in the aortic position.