Mechanical aortic valve leaflet immobility

Case contributed by Dr Issac Yang

Presentation

Patient with mechanical aortic valve prosthesis

Patient Data

Age: 80 years
Gender: Male
DSA (angiography)

There is a St. Jude bileaflet prosthetic aortic valve. One leaflet is immobile in the closed position. The other leaflet demonstrates normal opening and closing.

Cardiac CT was requested to assess for pannus or thrombus as a cause for the immobile valve leaflet. A subtle thin semicircular hypodensity can be seen at the subprosthetic aspect of the valve ring adjacent to the immobile leaflet, suggestive of pannus formation.

Case Discussion

After the exclusion of patient prosthesis mismatch, the most common cause of acquired mechanical prosthetic heart valve obstruction is thrombosis or pannus formation, with an incidence of 0.4-6% per year depending on valve type and position. Differentiation of the two entities is of significant importance as valve thrombosis can be potentially ameable to thrombolysis.

Cardiac CT allows for the evaluation of leaflet opening and closing angles, dynamic leaflet motion and the composition of perivalvular masses to aid with differentiate between valve thrombosis and pannus formation. Pannus are found below the aortic prosthesis. They are circular or semicircular extending from the prosthesis ring, and enhance with contrast. Thrombus can be found above or below the valve prosthesis and tend to be irregularly shaped and attached to the leaflet or hingepoint. An attenuation cut-off of >145 HU has been recommended for differentiating pannus from thrombus.

The patient underwent redo aortic valve replacement. Subvalvular pannus formation was confirmed to be the cause of leaflet immobility on the explanted valve prosthesis. A bioprosthetic valve was implanted.

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