Complete Prosthetic Aortic Valve Dehiscence and Distal Migration, Emergent Intervention and Predictive Insight
Presented During:
Saturday, May 6, 2023: 5:00PM - Monday, May 8, 2023: 3:45PM
Los Angeles Convention Center
Posted Room Name:
ePoster Area, Exhibit Hall
Abstract No:
6066
Submission Type:
Cardiothoracic Resident Case Report Competition
Authors:
Shane Smith (1), Lola Chabtini (2), Jeffrey Everett (3), Joel Corvera (4)
Institutions:
(1) N/A, United States, (2) Indiana University, Indianapolis , IN, (3) N/A, Indianapolis, IN, (4) IU Health Methodist Hospital, Indianapolis, IN
Submitting Author:
Shane Smith
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Co-Author(s):
Lola Chabtini
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Indiana University
Indiana University
Jeffrey Everett
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Joel Corvera
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IU Health Methodist Hospital
IU Health Methodist Hospital
Presenting Author:
Shane Smith
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Abstract:
A 55-year-old male with history of mechanical aortic and mitral valve replacement for endocarditis nine years prior presented to our institution with chest pain and dyspnea in cardiogenic shock. He quickly decompensated requiring high doses of vasopressors and he developed respiratory and renal failure requiring mechanical ventilation and continuous renal replacement therapy. Transesophageal echocardiography demonstrated severe aortic regurgitation, but was unable to reasonably visualize the mechanical aortic valve leaflets due to shielding from the mitral prothesis. On fluoroscopy, the entire aortic prosthesis was missing from the its annulus and was found to have migrated distally in the descending thoracic aorta with position adequate for distal blood flow in systole.
The patient was taken to the operating room from the cath lab for redo aortic valve replacement with a 23 mm mechanical aortic valve. Since there were no concerns for distal ischemia, the migratory aortic prosthesis was left in situ for retrieval at a later time after recovery from acute shock and multisystem organ failure.
The post-operative course was prolonged, but the patient recovered respiratory and kidney function. At discharge, he had decreased cardiac function with an ejection fraction of 19%. He was sent home on post-operative day fourteen with the migratory aortic valve in situ on therapeutic anticoagulation with a life vest defibrillator.
The patient was followed closely and eventually underwent removal of the migratory valve seven months later by our aortic specialist through a thoracoabdominal approach. This was done under cardiopulmonary bypass with cannulation in the descending thoracic aorta, left common femoral artery, and left common femoral vein. The prosthesis was palpated in the supra celiac aorta. The aorta was clamped at T10 and infrarenally, it was then opened and the valve was removed along with some adherent old clot. The prosthesis eroded into the media of the aorta so an interposition graft was used to replace this portion.
On review of the case, the valve was clearly visible on chest x-ray in the emergency room in a migratory position (Figure), but this was overlooked due to this uncommon presentation. Also, in a retrospective analysis of this patient's cath, performed three years prior to evaluate for coronary disease, the aortic valve prothesis is seen moving up and down or "rocking" within the aortic annulus. Rocking is consistent with dehiscence which is a rare complication in itself, but complete dehiscence and migration of the prosthetic valve is very unusual. Careful review of valve prostheses is essential during any heart catheterization as it may demonstrate issues that could be intervened upon prior to serious complications.
Wide open aortic insufficiency places severe stress on the cardiac myocardium from both inadequate coronary perfusion and elevated left ventricular end diastolic pressure. In our patient, this scenario resulted in acute cardiogenic shock and multi-system organ failure. In this case, our primary goal in management was to fix the acute severe aortic insufficiency. Since there were no signs of mesenteric ischemia and angiography showed good renal and distal perfusion, we decided to leave the migratory valve in situ. We feel this decision was paramount to this patient's survival.
The patient was taken to the operating room from the cath lab for redo aortic valve replacement with a 23 mm mechanical aortic valve. Since there were no concerns for distal ischemia, the migratory aortic prosthesis was left in situ for retrieval at a later time after recovery from acute shock and multisystem organ failure.
The post-operative course was prolonged, but the patient recovered respiratory and kidney function. At discharge, he had decreased cardiac function with an ejection fraction of 19%. He was sent home on post-operative day fourteen with the migratory aortic valve in situ on therapeutic anticoagulation with a life vest defibrillator.
The patient was followed closely and eventually underwent removal of the migratory valve seven months later by our aortic specialist through a thoracoabdominal approach. This was done under cardiopulmonary bypass with cannulation in the descending thoracic aorta, left common femoral artery, and left common femoral vein. The prosthesis was palpated in the supra celiac aorta. The aorta was clamped at T10 and infrarenally, it was then opened and the valve was removed along with some adherent old clot. The prosthesis eroded into the media of the aorta so an interposition graft was used to replace this portion.
On review of the case, the valve was clearly visible on chest x-ray in the emergency room in a migratory position (Figure), but this was overlooked due to this uncommon presentation. Also, in a retrospective analysis of this patient's cath, performed three years prior to evaluate for coronary disease, the aortic valve prothesis is seen moving up and down or "rocking" within the aortic annulus. Rocking is consistent with dehiscence which is a rare complication in itself, but complete dehiscence and migration of the prosthetic valve is very unusual. Careful review of valve prostheses is essential during any heart catheterization as it may demonstrate issues that could be intervened upon prior to serious complications.
Wide open aortic insufficiency places severe stress on the cardiac myocardium from both inadequate coronary perfusion and elevated left ventricular end diastolic pressure. In our patient, this scenario resulted in acute cardiogenic shock and multi-system organ failure. In this case, our primary goal in management was to fix the acute severe aortic insufficiency. Since there were no signs of mesenteric ischemia and angiography showed good renal and distal perfusion, we decided to leave the migratory valve in situ. We feel this decision was paramount to this patient's survival.
Category:
Adult Cardiac
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