Stuck Mechanical Tricuspid Valve Prosthesis

Abstract

A 44-year-old woman underwent mitral valve and tricuspid valve (TV) replacement 6 years earlier using an ATS bileaflet tilting disc prostheses (ATS Medical Inc., Minneapolis, MN) for combined valvular stenosis and regurgitation because of rheumatic heart disease. On a routine clinic visit, the patient reported progressive fatigue and pedal edema over the previous few weeks. On physical examination, she was hemodynamically stable with evidence of elevated jugular venous pressure, hepatomegaly, and 3-mm pitting ankle and leg edema. Cardiac auscultation revealed closing and opening mechanical clicks; however, mitral and tricuspid clicks could not be distinguished. A grade 2/6 holodiastolic rumble and a grade 2/6 systolic murmur were audible at the left lower sternal border. An ECG showed atrial fibrillation with a ventricular rate at 75 beats per minute. Baseline laboratory investigations showed an international normalized ratio level of 1.8 with white cell count of 4960/mm 3 , erythrocyte sedimentation rate of 9 mm/h, and C-reactive protein level of 4 mg/L. Blood cultures were negative. A transthoracic echocardiogram showed both mechanical tricuspid discs stuck in a fully open position throughout the cardiac cycle ( Figure 1A and 1B and online-only Data Supplement Movies I and II). A mobile structure was intermittently noted in the medial inflow portion of the tricuspid prosthesis suggestive of either a thrombus or vegetation ( Figure 1C and online-only Data Supplement Movie III). Color Doppler showed diastolic turbulence across the TV with evidence of transvalvular tricuspid regurgitation ( Figure 1D and online-only Data Supplement Movie IV). On spectral Doppler, TV gradients were significantly elevated with absent valve clicks and prolonged pressure half-time (Figure 2). Findings of stuck TV discs were confirmed by fluoroscopy (Figure 3 and onlineonly Data Supplement Movie V) and transesophageal echocardiography (Figure 4 and online-only Data Supplement Movie VI). The latter also confirmed the presence of a small There is absence of opening and closing clicks of the tricuspid valve with markedly elevated gradients (peak/mean gradientsϭ26/16 mm Hg at heart rate of 72 beats per minute) and significant prolongation of the pressure halftime at 235 ms. Tricuspid regurgitation is also evident (arrow). From the King Faisal

Intermittent Entrapment of a Prosthetic Mitral Valve Disc

“…Assessment of the presence and timing of valve clicks provides valuable information regarding prosthesis function. 4 A normal transprosthetic gradient does not exclude the presence of MV obstruction especially if this is intermittent; however, prolongation of the pressure half-time is usually evident (Figure 2). 1 Intermittent prosthetic valve dysfunction can have catastrophic consequences and thus requires prompt diagnosis and treatment.…”