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• W2051028228 abstract "HomeCirculationVol. 122, No. 15Unusual Cause of Stroke After Mitral Valve Replacement Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBUnusual Cause of Stroke After Mitral Valve Replacement J.Y. Tabet, E. Bouvier, B. Cormier, P. Donzeau-Gouge, D. Fourchy, P. Seknadji, Y. Laurent, B. Galet and M.C. Malergue J.Y. TabetJ.Y. Tabet From the Institut Jacques Cartier, Massy (J.Y.T., E.B., B.C., P.D.-G., D.F., P.S., Y.L., M.C.M.); Hôpital Lariboisière, INSERM U 942, Paris (J.Y.T.); Centre de Réadaptation Cardiovasculaire de la Brie, Villeneuve Saint Denis (J.Y.T.); and Bievre Laboratory, Bièvres (B.G.), France. Search for more papers by this author , E. BouvierE. Bouvier From the Institut Jacques Cartier, Massy (J.Y.T., E.B., B.C., P.D.-G., D.F., P.S., Y.L., M.C.M.); Hôpital Lariboisière, INSERM U 942, Paris (J.Y.T.); Centre de Réadaptation Cardiovasculaire de la Brie, Villeneuve Saint Denis (J.Y.T.); and Bievre Laboratory, Bièvres (B.G.), France. Search for more papers by this author , B. CormierB. Cormier From the Institut Jacques Cartier, Massy (J.Y.T., E.B., B.C., P.D.-G., D.F., P.S., Y.L., M.C.M.); Hôpital Lariboisière, INSERM U 942, Paris (J.Y.T.); Centre de Réadaptation Cardiovasculaire de la Brie, Villeneuve Saint Denis (J.Y.T.); and Bievre Laboratory, Bièvres (B.G.), France. Search for more papers by this author , P. Donzeau-GougeP. Donzeau-Gouge From the Institut Jacques Cartier, Massy (J.Y.T., E.B., B.C., P.D.-G., D.F., P.S., Y.L., M.C.M.); Hôpital Lariboisière, INSERM U 942, Paris (J.Y.T.); Centre de Réadaptation Cardiovasculaire de la Brie, Villeneuve Saint Denis (J.Y.T.); and Bievre Laboratory, Bièvres (B.G.), France. Search for more papers by this author , D. FourchyD. Fourchy From the Institut Jacques Cartier, Massy (J.Y.T., E.B., B.C., P.D.-G., D.F., P.S., Y.L., M.C.M.); Hôpital Lariboisière, INSERM U 942, Paris (J.Y.T.); Centre de Réadaptation Cardiovasculaire de la Brie, Villeneuve Saint Denis (J.Y.T.); and Bievre Laboratory, Bièvres (B.G.), France. Search for more papers by this author , P. SeknadjiP. Seknadji From the Institut Jacques Cartier, Massy (J.Y.T., E.B., B.C., P.D.-G., D.F., P.S., Y.L., M.C.M.); Hôpital Lariboisière, INSERM U 942, Paris (J.Y.T.); Centre de Réadaptation Cardiovasculaire de la Brie, Villeneuve Saint Denis (J.Y.T.); and Bievre Laboratory, Bièvres (B.G.), France. Search for more papers by this author , Y. LaurentY. Laurent From the Institut Jacques Cartier, Massy (J.Y.T., E.B., B.C., P.D.-G., D.F., P.S., Y.L., M.C.M.); Hôpital Lariboisière, INSERM U 942, Paris (J.Y.T.); Centre de Réadaptation Cardiovasculaire de la Brie, Villeneuve Saint Denis (J.Y.T.); and Bievre Laboratory, Bièvres (B.G.), France. Search for more papers by this author , B. GaletB. Galet From the Institut Jacques Cartier, Massy (J.Y.T., E.B., B.C., P.D.-G., D.F., P.S., Y.L., M.C.M.); Hôpital Lariboisière, INSERM U 942, Paris (J.Y.T.); Centre de Réadaptation Cardiovasculaire de la Brie, Villeneuve Saint Denis (J.Y.T.); and Bievre Laboratory, Bièvres (B.G.), France. Search for more papers by this author and M.C. MalergueM.C. Malergue From the Institut Jacques Cartier, Massy (J.Y.T., E.B., B.C., P.D.-G., D.F., P.S., Y.L., M.C.M.); Hôpital Lariboisière, INSERM U 942, Paris (J.Y.T.); Centre de Réadaptation Cardiovasculaire de la Brie, Villeneuve Saint Denis (J.Y.T.); and Bievre Laboratory, Bièvres (B.G.), France. Search for more papers by this author Originally published12 Oct 2010https://doi.org/10.1161/CIRCULATIONAHA.110.945014Circulation. 2010;122:e484–e485A 78-year-old woman was admitted to the hospital because of ischemic stroke with regressive right hemiplegia. Two years earlier, she had undergone a supra-annular mitral valve replacement with a porcine bioprosthesis (St Jude Medical Epic No. 27, St. Jude Medical, Inc., St. Paul, Minn). Because of paroxysmal atrial fibrillation, she had received vitamin K antagonist treatment since the surgery. At admission, the patient was asymptomatic and had no fever. Physical examination revealed a 2/6 apical diastolic murmur.Transthoracic echocardiography performed at admission revealed several extensive vibratile masses attached to the prosthesis ring. Mean mitral gradient was 11 mm Hg, which indicated prosthesis obstruction. Maximal systolic pulmonary pressure was 47 mm Hg. Left ventricular ejection fraction was 50% as assessed by the biplane Simpson method. Two- and 3-dimensional transesophageal echocardiography showed that the cusps of the bioprosthesis and left atrial endothelium became covered with tissue overgrowth and confirmed the presence of voluminous vibratile-added masses (the longest component was 19 mm) attached to the prosthesis ring with a protrusive extent onto the prosthetic orifice leading to mitral prosthesis obstruction (Figure 1 and Movies I and II in the online-only Data Supplement).Download figureDownload PowerPointFigure 1. Extensive vibratile masses attached to the bioprosthesis ring and tissue growth covering the cusps of the bioprosthesis and left atrial endothelium on 2- dimensional transesophageal echocardiography.Carotid ultrasonography revealed no significant lesions. A diagnosis of bioprosthesis obstruction related to thrombosis or infection was suspected. However, the international normalized ratio and C-reactive protein measurements were 2.3 and 5 mg/L, respectively, and hemocultures were negative.Because of her recent stroke and the presence of voluminous masses leading to prosthesis obstruction, the patient underwent a redo bioprosthesis replacement. Peroperative observations showed the presence of extensive fibrous pannus on the left atrial endothelium and prosthesis cusps, with several mobile components in the prosthetic orifice leading to obstruction of the prosthesis (Figure 2). Pathology examination confirmed the extensive pannus in-growth without thrombus or endocardial damage (Figure 3). Cultures were negative.Download figureDownload PowerPointFigure 2. Atrial (A) and ventricular (B) views of the explanted prosthesis. The fibrous pannus covers the ring and extends onto the prosthesis orifice.Download figureDownload PowerPointFigure 3. Extensive organized fibrous (presence of fibrocytes with black nucleus) with no inflammatory cells.Bioprosthetic heart valves undergo tissue deterioration characterized by tissue degeneration, calcifications, cusp tears, and sometimes fibrous pannus. Pannus is composed of fibroblasts and collagen fibers, which reflect tissue reaction at the site of implantation. Some coexisting factors such as the prosthetic valve design, biocompatibility, surgical techniques, prosthetic valve size in cases of smaller annuli, blood flow turbulence, shear stress, inadequate anticoagulation, and sustained inflammation may contribute to pannus formation.1,2 Mitral chord preservation3 and subannular ring implantation4 may favor the formation of pannus on mitral bioprostheses by increasing the close proximity and repeated contact of the preserved mitral tissue with the prosthesis ring. However, most of the time, collagen extension remains limited near the ring, and extensive pannus in-growth, especially in the bioprostheses mitral site, is an uncommon cause of valve failure. Bortolotti et al4 first described 2 cases of Hancock bioprosthetic mitral stenosis caused by tissue overgrowth on the atrial aspect of the cusps 5 and 6 years after implantation. In our case, the discovery of vibratile masses on the prosthesis, combined with the patient's recent stroke, led us to suspect thrombosis or infection.To the best of our knowledge, this is the first reported case of cerebral ischemic attack related to an isolated, extensive, protruding pannus on a mitral bioprosthesis with several mobile components and mimicking thrombosis or endocarditis lesions on echocardiography.DisclosuresNone.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/122/15/e484/DC1.Correspondence to Dr J.Y. Tabet, Institut Jacques Cartier, 6 Rue du Noyer Lambert, 91300 Massy, France. E-mail jtabet@free.frReferences1. Vitale N, Renzulli A, Agozzino L, Pollice A, Tedesco N, de Luca Tupputi Schinopsa L, Cotrufo M. Obstruction of mechanical mitral prostheses: analysis of pathologic findings. Ann Thorac Surg. 1997; 63:1101–1106.CrossrefMedlineGoogle Scholar2. Teshima H, Hayashida N, Yano H, Nishimi M, Tayama E, Fukunaga S, Akashi H, Kawara T, Aoyagi S. Obstruction of St Jude Medical valves in the aortic position: histology and immunohistochemistry of pannus. J Thorac Cardiovasc Surg. 2003; 126:401–407.CrossrefMedlineGoogle Scholar3. Butany J, Yu W, Silver MD, David TE. Morphologic findings in explanted Hancock II porcine bioprostheses. J Heart Valve Dis. 1999; 8:4–15.MedlineGoogle Scholar4. Bortolotti U, Gallucci V, Casarotto D, Thiene G. Fibrous tissue overgrowth on Hancock mitral xenografts: a cause of late prosthetic stenosis. Thorac Cardiovasc Surg. 1979; 27:316–318.CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Chang S, Suh Y, Han K, Kim J, Kim Y, Chang B and Choi B (2017) The clinical significance of perivalvular pannus in prosthetic mitral valves: Can cardiac CT be helpful?, International Journal of Cardiology, 10.1016/j.ijcard.2017.09.169, 249, (344-348), Online publication date: 1-Dec-2017. Arnáiz-García M, González-Santos J, Arévalo-Abascal A, Bueno-Codoñer M, Dalmau-Sorlí M, López-Rodríquez J and Arribas-Jiménez A (2015) Pannus subvalvular como causa de desproporción tardía prótesis-paciente después de sustitución de la válvula aórtica, Archivos de Cardiología de México, 10.1016/j.acmx.2014.09.006, 85:2, (168-169), Online publication date: 1-Apr-2015. Arnáiz-García M, González-Santos J, Bueno-Codoñer M, López-Rodríguez J, Dalmau-Sorlí M, Arévalo-Abascal A, Arribas-Jiménez A, Diego-Nieto A, Rodríguez-Collado J and Rodríguez-López J (2015) Perivalvular pannus and valve thrombosis: Two concurrent mechanisms of mechanical valve prosthesis dysfunction, Revista Portuguesa de Cardiologia (English Edition), 10.1016/j.repce.2014.08.023, 34:2, (141.e1-141.e3), Online publication date: 1-Feb-2015. Arnáiz-García M, González-Santos J, Bueno-Codoñer M, López-Rodríguez J, Dalmau-Sorlí M, Arévalo-Abascal A, Arribas-Jiménez A, Diego-Nieto A, Rodríguez-Collado J and Rodríguez-López J (2015) Perivalvular pannus and valve thrombosis: Two concurrent mechanisms of mechanical valve prosthesis dysfunction, Revista Portuguesa de Cardiologia, 10.1016/j.repc.2014.08.024, 34:2, (141.e1-141.e3), Online publication date: 1-Feb-2015. October 12, 2010Vol 122, Issue 15 Advertisement Article InformationMetrics © 2010 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.110.945014PMID: 20937984 Originally publishedOctober 12, 2010 PDF download Advertisement SubjectsCardiovascular SurgeryEchocardiographyIschemic Stroke" @default.
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