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Long-term event-free survival with an embolised prosthetic valve leaflet in the thoracic aorta.
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MedLine Citation:
PMID:  18513417     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
We report the case of a patient who underwent a redo surgery for a leaflet escape from a Bjork-Shiley tilting disc mitral prosthesis inserted 18 years previously. The escaped disc remained lodged in the thoracic aorta without any complication. She ultimately died of terminal heart failure 13 years after the second operation. We believe this to be the longest survival with a dislodged leaflet from a mechanical valve. Removal of dislodged disc is recommended in literature but there may be a place for watchful observation in exceptional cases with no haemodynamic compromise.
Authors:
Mohan P Devbhandari; Edwin B C Woo; Timothy L Hooper
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Publication Detail:
Type:  Case Reports; Journal Article     Date:  2008-05-30
Journal Detail:
Title:  Journal of cardiothoracic surgery     Volume:  3     ISSN:  1749-8090     ISO Abbreviation:  J Cardiothorac Surg     Publication Date:  2008  
Date Detail:
Created Date:  2008-09-12     Completed Date:  2008-12-02     Revised Date:  2010-09-22    
Medline Journal Info:
Nlm Unique ID:  101265113     Medline TA:  J Cardiothorac Surg     Country:  England    
Other Details:
Languages:  eng     Pagination:  34     Citation Subset:  IM    
Affiliation:
Department of Cardiothoracic Surgery, South Manchester University Hospital, Manchester, UK. mohandev@hotmail.com
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MeSH Terms
Descriptor/Qualifier:
Aorta, Thoracic*
Diagnosis, Differential
Disease-Free Survival
Echocardiography, Transesophageal
Embolism / etiology*,  surgery,  ultrasonography
Fatal Outcome
Female
Follow-Up Studies
Foreign-Body Migration / complications*,  surgery,  ultrasonography
Heart Valve Prosthesis / adverse effects*
Humans
Middle Aged
Mitral Valve Stenosis / surgery*
Prosthesis Failure
Reoperation
Time Factors
Comments/Corrections

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): J Cardiothorac Surg
ISSN: 1749-8090
Publisher: BioMed Central
Article Information
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Copyright ? 2008 Devbhandari et al; licensee BioMed Central Ltd.
open-access: This is an Open Access article distributed under the terms of the Creative Commons Attribution License (), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received Day: 1 Month: 8 Year: 2007
Accepted Day: 30 Month: 5 Year: 2008
collection publication date: Year: 2008
Electronic publication date: Day: 30 Month: 5 Year: 2008
Volume: 3First Page: 34 Last Page: 34
ID: 2533661
Publisher Id: 1749-8090-3-34
PubMed Id: 18513417
DOI: 10.1186/1749-8090-3-34

Long-term event-free survival with an embolised prosthetic valve leaflet in the thoracic aorta
Mohan P Devbhandari1 Email: mohandev@hotmail.com
Edwin BC Woo1 Email: edwinwoo@bigfoot.com
Timothy L Hooper1 Email: Tim.Hooper@smuht.nwest.nhs.uk
1Department of Cardiothoracic Surgery, South Manchester University Hospital, Manchester, UK

Introduction

Leaflet escape from a prosthetic valve is a rare but life-threatening event. Treatment is by emergency replacement of the prosthesis and retrieval of the escaped leaflet. Reported literatures till date suggest that failure to retrieve the embolised leaflet will lead to arterial or hemodynamic complications that may have dire consequences for the patient [1].


Case report

A 52 year old lady underwent mitral valve replacement with a 23 mm Bj?rk-Shiley prosthesis18 years previously for rheumatic mitral stenosis. Latterly she had suffered with refractory supraventricular tachyarrhythmias and a transeptal AV node ablation was attempted. Unfortunately she became acutely unwell during the procedure, with cardiogenic shock and pulmonary oedema, which proved to be due to escape of the disc-occluder from the valve prosthesis during the cardiological maneuver. She underwent emergency surgery to replace the damaged valve with a bileaflet device, but the escaped disc could not be found. It was later localized by trans-esophageal echocardiography to the descending thoracic aorta, with its long axis parallel to the long axis of aorta, thus not interrupting the flow.

Postoperatively, she had a protracted intensive care stay with multi-system failure, and was not considered to be well enough to contemplate removal of the embolised leaflet. After discussion among the treating clinicians and family members a decision to "wait and watch" was adopted, with the question of further surgery being postponed until the patient's condition improved. She was eventually discharged from hospital after two months. By that time it was established that the patient did not want to pursue further intervention to remove the disc. She had been attending annual reviews for thirteen years and has had no problems referable to the embolised disc. She ultimately died of terminal heart failure. Post mortem examination was declined by the relatives.


Discussion

Leaflet escape from a prosthetic valve has been reported following both mitral and aortic valve replacement surgery at variable intervals of time ranging from days to several years after the date of operation [2]. The causes for leaflet escape have been ascribed mainly to pivot system fracture [2,3] or disc fracture [4] though rarely it can follow interventional cardiological maneuvers as in our case.

The usual mode of presentation is with acute severe shortness of breath, often after a period of activity. Clinically, the picture is of acute left ventricular failure and pulmonary edema with cardiogenic shock, due to severe valvular incompetence [1-4]. Possible differential diagnosis that needs to be ruled out are myocardial infarction, para prosthetic valvular leak, malignant arrhythmia and pulmonary embolism.

Echocardiography is not always diagnostic of the leaflet escape and may be interpreted as showing obstructed closure of the prosthetic valve or a paravalvular leak. The picture can be confusing and misinterpreted as showing valve thrombosis resulting in anticoagulant therapy causing delay in life-saving surgery and death of patient [5].

Timely diagnosis and emergency surgical replacement of the damaged prosthetic valve is indicated. Delay in diagnosis or treatment may prove to be detrimental [2,5]. It is sometimes difficult to locate the missing leaflet which may have embolised more distally in the aorta [3,5] or iliac artery [1]. Plain radiographs often fail to visualize the disc as they are not sufficiently radio opaque. Ultrasound and CT scan are more accurate at localizing the dislodged leaflet [6,7] in most reported cases. Fluoroscopy [5] has also been used in some cases to localize the leaflet.

In the reported literature, it has been considered mandatory to retrieve the embolised disc at the same time or shortly after valve replacement [1]. Rarely the leaflets eluded all attempts at localization and were discovered only at autopsy [5].

There are only few reports of patient achieving long term survival, without complications, with a mechanical valve leaflet lodged in thoracic aorta. This we believe is the case with the longest survival. Previous authors have emphasized that it is mandatory to remove the foreign body due to risk of thrombosis, migration, erosion and infection at the site of lodgment. The critical condition of our patient at presentation along with absence of hemodynamic obstruction prompted us to follow a wait and watch policy against this recommendation, which proved a successful strategy.


Conclusion

Following emergency surgery for prosthetic valve leaflet escape, there may be a place for watchful observation of the escaped disc if it is not causing haemodynamic compromise and the patient's condition or wishes prevents surgical removal.


Consent

The patient has been deceased for several years and the relatives were not contactable at this time. Please contact the editor for further details.


Competing interests

The authors declare that they have no competing interests.


Authors' contributions

MD designed the paper and prepared the manuscript, EW revised the manuscript, TH performed the operation and revised the contents of the paper. All authors read and approved the final manuscript.


Acknowledgements

We would like to thank Ms Julie Reed, cardiothoracic secretary who helped us collect all the materials going back more than a decade.


References
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Bottio T,Casarotto D,Thiene G,Caprili L,Angelini A,Gerosa G. Leaflet escape in a new bileaflet mechanical valve: TRI technologiesCirculation 2003;107:2303–6. [pmid: 12732611] [doi: 10.1161/01.CIR.0000070590.42796.F0]
Hjelms E. Escape of a leaflet from a St. Jude Medical prosthesis in the mitral positionThorac Cardiovasc Surg 1983;31:310–2. [pmid: 6196867]
Kornberg A,Wildhirt SM,Schulze C,Kreuzer E. Leaflet escape in Omnicarbon monoleaflet valveEur J Cardiothorac Surg 1999;15:867–9. [pmid: 10431873] [doi: 10.1016/S1010-7940(99)00109-8]
Deuvaert FE,Devriendt J,Massaut J,Van Nooten G,De Paepe J,Primo G. Leaflet escape of a mitral Duromedics prosthesis. Case reportActa Chir Belg 1989;89:15–8. [pmid: 2718682]
Yildlz A,Ozer C,Kara E,Apaydin FD,Duce MN,Egilmez H. A case of missing mitral valve leaflet: radiological detectionEur Radiol 2003;13:L11–3. [pmid: 15018159]
Kumar B,Mirsadraee S,Oswal D,Kaul P. Use of a Fogarty Embolectomy Catheter to Retrieve a Foreign Body during Redo Coronary Artery Bypass Surgery: Case ReportHeart Surg Forum 2004;7:105–106. [pmid: 14980857]

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