Role of cine-fluoroscopy, transthoracic, and transesophageal echocardiography in patients with suspected prosthetic heart valve thrombosis

Prosthetic heart valve thrombosis (PVT) is a rare but potentially life-threatening complication of heart valve replacement. An effective, quick, and easy diagnostic method is highly desirable. We evaluated the diagnostic efficacy of cine-fluoroscopy (CF), transthoracic (TTE), and transesophageal (TEE) echocardiography in 82 consecutive patients with mechanical valves and suspected PVT. Criteria for PVT were: leaflet(s) motion restriction at CF, increased Doppler gradients at TTE, and evidence of thrombi at TEE. Patients were divided in 4 groups (A, B, C, and D) according to results of CF and TTE. Group A was composed of 24 patients with positive CF and TTE. Thrombi were detected by TEE in all cases, suggesting that when both are positive, CF and TTE correctly identified PVT in all patients so that TEE may be deferred. Group B was composed of 12 patients with positive CF and negative TTE; TEE showed PVT in 4 patients (33%). These patients had very slight leaflet motion restriction as in the case of initial PVT. This suggests that CF compared with Doppler may identify patients with "hemodynamically significant" PVT. The remaining 8 patients in this group had monocuspid prostheses with negative TEE, suggesting that abnormal leaflet motion at CF may be due to functional changes. Therefore, TEE should always be performed in case of monocuspid prostheses with isolated CF abnormalities. Group C was composed of 18 asymptomatic patients with small-sized aortic prostheses and very high Doppler gradients on routine TTE. CF showed normal leaflet motion and TEE ruled out PVT in all cases outlining the diagnostic role of CF in this particular subset. Finally, group D was composed of 28 patients with negative CF and TTE. TEE did not show thrombi in 24 of 28 patients (86%), confirming that, when both yield negative results, CF and TTE are reliable methods to rule out valve thrombosis in most cases. However, in 4 of 28 patients (14%) TEE showed "nonobstructive" prosthetic thrombosis: these patients had mitral prostheses, chronic atrial fibrillation, and 3 of 4 had systemic embolisms. Thus, TEE should be performed in selected patients despite negative CF and TTE results. Sensitivity, specificity, and positive and negative predictive values were 87%, 78%, 80%, and 91% for CF and 75%, 64%, 57%, and 78% for TTE, respectively. CF and TTE correctly identified PVT in 70 of 82 patients (85%). TEE was actually required in 15% of the cases. Thus, CF and TTE are quick, effective, and complementary diagnostic tools to diagnose PVT in most patients. TEE still remains the gold standard technique in selected cases.

Thrombosis of mechanical heart valve prostheses: revisiting the role of fluoroscopy

Prosthetic valve thrombosis is a rare but potentially fatal complication of heart valve replacement. Symptoms may be misleading, yet the condition may rapidly lead to death. A prompt diagnosis is therefore crucial. Ultrasound is the most often used technique for evaluating prosthesis dysfunction. We describe two cases of prosthesis thrombosis with negative Doppler results but with distinctly abnormal leaflet motion at fluoroscopy. A correct diagnosis would have been missed if the Doppler evaluation alone was relied on. Fluoroscopy should always form part of the diagnostic work-up in patients with artificial heart valves.

[Surgical therapy for prosthetic infections of the thoracic aorta. Conservative approach]

The prosthetic graft infection of the thoracic aorta is a dreaded complication and it is associated with a high mortality rate. There is not substantial agreement in literature about how to manage a vascular graft infection, except for local anti-septic irrigation with a systemic antibiotic therapy. The main point of discussion is if it is mandatory to remove or not the infected thoracic aorta prosthesis: some authors prefer to eliminate all the thoracic aortic prostheses which may be infected, while others propose graft removal only when the sutures lines are involved. In this paper we report our experience on the conservative management of infected thoracic aorta prostheses using a local antiseptic irrigation, a perigraft debridement and leaving the original graft "in situ" when there is evidence of graft damage especially or involvement of the sutures lines. This approach has been performed in three patients: two had an infected aortic arch prosthesis, while one had a descending thoracic aorta prosthesis infection.

[Heart surgery, cardiopulmonary bypass, and organic inflammatory response. Part II: changes in leukocytes, arachidonic acid derivatives, and hormones]

The use of cardiopulmonary bypass for surgical cardiac procedures is characterized by a whole-body inflammatory reaction due to the contact of blood through nonendothelialized surfaces; this stimulates the organism to recognize the cardiopulmonary bypass system as "nonself" and to activate specific (immune) and nonspecific (inflammatory) responses. These responses are then related with postoperative damage to many body systems of the body, like pulmonary, renal or brain dysfunction, excessive bleeding and postoperative sepsis. In this paper, present knowledge on untoward responses of the patient to cardiopulmonary bypass in cardiac surgery is reviewed and discussed, particularly focusing on the perturbation of the leukocytes, of the hormones and of the products of the arachidonic acid cascade.

Fluoroscopic functional evaluation of bileaflet prostheses: effect of different intraoperative valve orientation

Fluoroscopy is a reliable, easy, and readily available technique to follow-up prosthesis functioning after heart valve surgery. The different orientation given to the prosthesis may represent a limitation of the technique accounting for unsatisfactory results in 10% to 40% of the cases. The aim of the study was to evaluate whether and to what extent different intraoperative valve orientation influence feasibility and accuracy of postoperative fluoroscopic evaluation of bileaflet prostheses. We prospectively evaluated 90 patients who had aortic, mitral, and/or tricuspid valve replacement with Sorin Bicarbon or CarboMedics bileaflet prostheses. Fifty percent of the patients in each group were randomly assigned to receive prostheses oriented in a perpendicular or a parallel position with respect to the ventricular septum. Fluoroscopic evaluation was considered appropriate when the prosthesis' "tilting disk" projection was obtained. The valve's hemodynamic performance was investigated through Doppler study. A proper fluoroscopic evaluation was rapidly (15 +/- 5 seconds) achieved in all patients with the former orientation, whereas it was impossible to obtain it in 8 of 20 (40%), 19 of 20 (95%), and 4 of 5 (80%) of patients with the latter orientation. In the remaining patients extremely angulated, uneasy projection was often required to get a correct fluoroscopic image. The Doppler study showed a similarly favorable hemodynamic performance regardless of valve orientation. Prosthesis orientation crucially affects the rate of success of the fluoroscopic evaluation. The orientation perpendicular to the ventricular septum greatly facilitates the postoperative feasibility and accuracy of fluoroscopy, and it is not detrimental to the valve's hemodynamic performance. This valve orientation may provide a better fluoroscopic window whenever a valve dysfunction is suspected.

Role of right gastroepiploic artery in myocardial revascularization with arterial grafts

Between July 1990 and December 1992. 112 patients underwent myocardial revascularization with arterial grafts in the Department of Cardiac Surgery, University of Milan. Monovascular patients were excluded from the study. The right gastroepiploic artery was used in 44 patients (39.3%); mean age was 54.3 years and reoperation rate 18.2%. Of the 44 patients, previous myocardial infarction had occurred in 25 (57%). Emergency operation was performed in one case (2%). Mean left ventricular shortening fraction was 36% and mean ejection fraction 58.6%. Coronary artery disease was bivascular in 10 patients (23%) and trivascular in 34 (77%). The arterial revascularization in patients with gastroepiploic artery was performed using a left internal thoracic artery graft in all 44 patients; the right internal thoracic artery was used in 18 (41%) and the inferior epigastric artery in two (4%). The sites of gastroepiploic artery grafting were 55% posterior descending, 16% right coronary artery, 11% posterolateral branch, 14% circumflex and in 4% posterior descending and posterolateral as sequential graft. No patient died; postoperative myocardial infarction rate was 4%. No complications related to gastroepiploic artery utilization were noted. Forty-three (98%) of the gastroepiploic artery group underwent graft reinvestigation: the arteries were correctly visualized in 41 patients (95%) and were patent in 39 cases and stenotic in two. A mid-term postoperative stress test (mean 17.4 months) was performed in 91% of patients. Normal limits were found in 37 patients (92.5%) and an abnormal stress test result in three (7.5%). The contemporary follow-up showed no deaths or myocardial infarctions. Three patients (7%) had recurrent angina. The role of gastroepiploic artery in arterial revascularization has become fundamental, especially, it is believed, for the posterior or posterolateral left ventricular wall. The present data show the patients to be clinically and functionally well 1 year after operation.

Valve design characteristics and cine-fluoroscopic appearance of five currently available bileaflet prosthetic heart valves

Bileaflet prostheses are low profile, central flow orifice devices that show excellent hemodynamic performance and low thrombogenicity. Five models are currently used for heart valve replacement. Comprehensive and comparative studies regarding valve characteristics and functioning are lacking, making the updating and the familiarization by physicians and cardiologists with these prostheses difficult. We describe the valve design characteristics and evaluate the cine-fluoroscopic appearance and functioning of 387 bileaflet prostheses that have been implanted in 367 consecutive patients. The valve types are St Jude Medical (n = 69), Edwards-Duromedics (n = 74), Carbomedics (n = 1290) Sorin Bicarbon (n = 88) and Jyros (n = 27). The prostheses' fluoroscopic appearance was evaluated through multiple radiographic views (Siemens-Elema equipment with C-arm); the prostheses' functional evaluation was performed by obtaining the "tilting disk projection" (ie, with the radiographic beam parallel to both the valve ring plane and the tilting axis of disks) to calculate opening, closing, and travel angles of the disks. This study shows that each of the five bileaflet valves has distinctive design characteristics. Fluoroscopy is an easy, readily available, and useful technique that correctly identifies the prosthesis type and properly evaluates its functioning in the majority of cases.

Ectopic thyroid tissue in the ventricular outflow tract: embryologic implications

The case of a 66-year-old female patient with a tumor located in the right ventricular outflow tract is reported. Histologic examination of an intraoperative biopsy revealed that the tumor was an intracardiac ectopic thyroid. We performed conservative surgery with partial resection of the mass. After 5 years, the patient is asymptomatic and leading a normal life. The authors examine the relation between the embryologic development of the primitive heart and the thyroid primordium and suggest the hypothesis of ectopic thyroid location in the right- or left-ventricular outflow tract.

Intracardiac ectopic thyroid: conservative surgical treatment

The case of a patient with an intracardiac ectopic thyroid is reported. A cardiac tumor was found in a 66-year-old woman and was diagnosed by two-dimensional echocardiography. An intraoperative biopsy was performed, and the mass was recognized as an ectopic thyroid and treated with a conservative surgical approach because of the size, location, and relationship to adjacent structures. The 60-month follow-up shows normal echocardiographic images and the good clinical status of the patient.