Cardiovascular Disease |

Bioprosthetic Mitral Valve Degeneration Fulfilling Duke Criteria FREE TO VIEW

Pranathi Sundaragiri, MBBS; Saraschandra Vallabhajosyula, MBBS; Amy Arouni, MD
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Department of Internal Medicine, Alegent-Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE

Chest. 2014;146(4_MeetingAbstracts):114A. doi:10.1378/chest.1988656
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SESSION TITLE: Cardiovascular Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: About 40% of implanted valves are bio-prosthetic (BP), with an annual risk of 6% for infective endocarditis (IE) and 0.03% for thrombosis1. Limited durability due to degeneration frequently necessitates valvular revision2. We herein report BP mitral valve (BPMV) degeneration mimicking IE.

CASE PRESENTATION: A 65-year old Caucasian male with atrial flutter, valvular heart disease and dilated cardiomyopathy presented with sudden complete loss of vision in the left eye. Patient received a BPMV and tricuspid annuloplasty in 1999 and was taken off anticoagulation 3 weeks ago for gastric hemorrhage. Fundoscopy demonstrated central retinal artery occlusion (CRAO) and retinal hemorrhages suggestive of Roth spots. Cardiac examination revealed stable hemodynamics, S3 gallop and new apical III/VI systolic murmur. Transesophageal echocardiogram demonstrated severe MV regurgitation; flail posterior leaflet and eccentric jet. Multiple mobile echo-densities were noted on the BPMV ring and leaflets. The patient was started on emergent antimicrobial therapy since he fulfilled one major and three minor Duke criteria for IE. The patient’s vision recovered with anticoagulation. In view of normal temperature, negative leukocytosis, negative procalcitonin and sterile cultures, he underwent mechanical MV replacement. Surgical pathology revealed calcified, degenerative BPMV, pannus and negative tissue cultures. Antimicrobials were discontinued and he was medically optimized with no symptoms at one-month follow-up.

DISCUSSION: IE is more common with BPMV and is often aggressive requiring prolonged antimicrobial therapy1. Thrombosis occurs in the first 1-2 years and valve failure in 7-8 years1,2. BPV have been implanted lesser in patients <60 years due to concerns for degeneration; however no mortality differences are noted2,3. In our patient, despite a time frame consistent with valve degeneration, fulfillment of Duke criteria subjected him to unnecessary antimicrobials. We hypothesize that the CRAO was a consequence of atrial flutter-induced transient thrombosis.

CONCLUSIONS: A careful clinical consideration in prosthetic valvular diseases with utilization of clinical, laboratory and imaging parameters for differentiation between thrombosis, embolism and degeneration is advocated.

Reference #1: Butany JW, Naseemuddin A, Nair V et al. Infective endocarditis in a hancock bioprosthetic valve. J Card Surg. 2005 Jul-Aug;20(4):389-92.

Reference #2: Hammermeister K, Sethi GK, Henderson WG et al. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol. 2000 Oct;36(4):1152-8.

Reference #3: Ruel M, Chan V, Bedard P et al. Very long-term survival implications of heart valve replacement with tissue versus mechanical prostheses in adults <60 years of age. Circulation. 2007 Sep 11;116(11 Suppl):I294-300.

DISCLOSURE: The following authors have nothing to disclose: Pranathi Sundaragiri, Saraschandra Vallabhajosyula, Amy Arouni

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