Accepted Manuscript Subvalvular pannus and thrombosis in a mitral valve prosthesis Gun Ha Kim, MD, Dong Hyun Yang, MD, PhD, Joon-Won Kang, MD, PhD, Dae-Hee Kim, MD, PhD, Sung-Ho Jung, MD, PhD, Tae-Hwan Lim, MD, PhD PII:
S1934-5925(15)30008-3
DOI:
10.1016/j.jcct.2015.09.004
Reference:
JCCT 836
To appear in:
Journal of Cardiovascular Computed Tomograph
Received Date: 16 August 2015 Revised Date:
12 September 2015
Accepted Date: 23 September 2015
Please cite this article as: Kim GH, Yang DH, Kang J-W, Kim D-H, Jung S-H, Lim T-H, Subvalvular pannus and thrombosis in a mitral valve prosthesis, Journal of Cardiovascular Computed Tomograph (2015), doi: 10.1016/j.jcct.2015.09.004. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Image in cardiovascular CT
RI PT
Subvalvular pannus and thrombosis in a mitral valve prosthesis
Gun Ha Kim, MD1; Dong Hyun Yang, MD, PhD1*; Joon-Won Kang, MD, PhD1; Dae-Hee
1
SC
Kim, MD, PhD2; Sung-Ho Jung, MD, PhD3; and Tae-Hwan Lim, MD, PhD1
Department of Radiology and Research Institute of Radiology; 2Division of Cardiology; and Department of Cardiovascular Surgery, Cardiac Imaging Center, Asan Medical Center,
M AN U
3
University of Ulsan College of Medicine, Seoul, South Korea
*Correspondence to:
TE D
All authors have no conflict of interest and financial disclosure to this work.
Dong Hyun Yang, M.D., Ph.D., Assistant Professor, Department of Radiology and Research
EP
Institute of Radiology, Cardiac Imaging Center, Asan Medical Center, University of Ulsan College of Medicine, Asanbyeongwon-gil 86, Seoul 138-736, South Korea.
AC C
Phone: 82-2-3010-5820; Fax: 82-2-476-8127; E-mail: [email protected]
Word count of text: 300
1
ACCEPTED MANUSCRIPT Abstracts A 69-year-old female underwent cardiac CT to evaluate prosthetic valve (PHV) dysfunction detected on echocardiography. A CT coronal and en face views of the mitral annular plane
RI PT
showed a low-density, mass-like lesion on the left atrial side of the PHV and a high-density, plate-like lesion on the left ventricular side of PHV. A repeat of the mitral valve replacement was performed, and preoperative CT findings of both the thrombus on the left atrial side and
SC
pannus formation on the LV side were confirmed in the operative findings.
M AN U
Case report
A 69-year-old female who had undergone mitral valve replacement 14 years earlier was admitted to evaluate a prosthetic heart valve (PHV) dysfunction detected on echocardiography. She has been adequately anticoagulated with warfarin recommended by
TE D
guideline. On echocardiography, the medial leaflet of the PHV did not move, and the mean transvalvular pressure gradient was increased to 9 mmHg. Cardiac CT was performed to evaluate the perivalvular abnormality and coronary artery disease. A CT coronal and en face
EP
views of the mitral annular plane 1 showed a low-density, mass-like lesion (white arrow) on the left atrial (LA) side of the PHV (CT density, 35–50 Hounsfield units), which was attached
AC C
to the medial valve strut (Figures 1A). On the left ventricular (LV) side of the PHV, there was a plate like lesion (arrowheads) encircling the outlet of the mitral PHV (Figures 1B). Interestingly, the LV side lesion displayed a relatively high CT density (130–180 Hounsfield units in a non-calcified area) with internal calcified foci (red arrow). This LV side lesion was considered to be the cause of the leaflet motion abnormality (Supplementary Video 1) and thought to be a subvalvular pannus formation. The preoperative CT findings of both thrombus and pannus formation were confirmed in the operative findings (Figures 1C and 1D). 2
ACCEPTED MANUSCRIPT Concurrent valve thrombosis and pannus formation has been reported as a rare occurrence2. Because the initial therapeutic approach to these two diseases may differ, the diagnosis of a valve thrombus and pannus by non-invasive imaging is important. Pannus
RI PT
formation may trigger thrombosis formation, and chronic thrombosis may also predispose a patient to pannus formation2. In a previous study, the pannus showed a relatively high CT density with a rim-like lesion3,4. In contrast, the thrombus displayed a lower CT density with
SC
an amorphous and irregular shape compared to the pannus5.
M AN U
Funding Sources
This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT, & Future
References 1.
TE D
Planning (NRF-2013R1A1A1058711).
Koo HJ, Yang DH, Oh SY, Kang JW, Kim DH, Song JK, Lee JW, Chung CH, Lim TH: Demonstration of mitral valve prolapse with CT for planning of mitral valve repair.
EP
Radiographics : a review publication of the Radiological Society of North America, Inc 2014;34:1537-1552.
Arnaiz-Garcia ME, Gonzalez-Santos JM, Bueno-Codoner ME, Lopez-Rodriguez J,
AC C
2.
Dalmau-Sorli MJ, Arevalo-Abascal A, Arribas-Jimenez A, Diego-Nieto A, RodriguezCollado J, Rodriguez-Lopez JM: Perivalvular pannus and valve thrombosis: Two concurrent mechanisms of mechanical valve prosthesis dysfunction. Revista portuguesa de cardiologia : orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology : an official journal of the Portuguese Society of Cardiology 2015;34:141 e141-143.
3.
Han K, Yang DH, Shin SY, Kim N, Kang JW, Kim DH, Song JM, Kang DH, Song JK, Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW, Lim TH: Subprosthetic Pannus after Aortic Valve Replacement Surgery: Cardiac CT Findings and Clinical Features. 3
ACCEPTED MANUSCRIPT Radiology 2015;276:724-731. 4.
Chung MS, Yang DH, Kim DH, Kang JW, Lim TH: Subvalvular pannus formation causing aortic stenosis in patient with a normal prosthetic aortic valve: computed tomography finding. European heart journal cardiovascular Imaging 2015;16:458. Ueda T, Teshima H, Fukunaga S, Aoyagi S, Tanaka H: Evaluation of prosthetic valve obstruction
on
electrocardiographically
gated
multidetector-row
computed
RI PT
5.
tomography--identification of subprosthetic pannus in the aortic position. Circulation
SC
journal : official journal of the Japanese Circulation Society 2013;77:418-423.
Supplemental Material
M AN U
Legends to supplementary videos
Video 1. Multiphase cardiac computed tomography (CT) showing motion limitation of the medial leaflet, thrombus formation on the left atrial surface, and pannus formation on the left
AC C
EP
TE D
ventricular surface.
4
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S1934-5925(15)30008-3
DOI:
10.1016/j.jcct.2015.09.004
Reference:
JCCT 836
To appear in:
Journal of Cardiovascular Computed Tomograph
Received Date: 16 August 2015 Revised Date:
12 September 2015
Accepted Date: 23 September 2015
Please cite this article as: Kim GH, Yang DH, Kang J-W, Kim D-H, Jung S-H, Lim T-H, Subvalvular pannus and thrombosis in a mitral valve prosthesis, Journal of Cardiovascular Computed Tomograph (2015), doi: 10.1016/j.jcct.2015.09.004. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Image in cardiovascular CT
RI PT
Subvalvular pannus and thrombosis in a mitral valve prosthesis
Gun Ha Kim, MD1; Dong Hyun Yang, MD, PhD1*; Joon-Won Kang, MD, PhD1; Dae-Hee
1
SC
Kim, MD, PhD2; Sung-Ho Jung, MD, PhD3; and Tae-Hwan Lim, MD, PhD1
Department of Radiology and Research Institute of Radiology; 2Division of Cardiology; and Department of Cardiovascular Surgery, Cardiac Imaging Center, Asan Medical Center,
M AN U
3
University of Ulsan College of Medicine, Seoul, South Korea
*Correspondence to:
TE D
All authors have no conflict of interest and financial disclosure to this work.
Dong Hyun Yang, M.D., Ph.D., Assistant Professor, Department of Radiology and Research
EP
Institute of Radiology, Cardiac Imaging Center, Asan Medical Center, University of Ulsan College of Medicine, Asanbyeongwon-gil 86, Seoul 138-736, South Korea.
AC C
Phone: 82-2-3010-5820; Fax: 82-2-476-8127; E-mail: [email protected]
Word count of text: 300
1
ACCEPTED MANUSCRIPT Abstracts A 69-year-old female underwent cardiac CT to evaluate prosthetic valve (PHV) dysfunction detected on echocardiography. A CT coronal and en face views of the mitral annular plane
RI PT
showed a low-density, mass-like lesion on the left atrial side of the PHV and a high-density, plate-like lesion on the left ventricular side of PHV. A repeat of the mitral valve replacement was performed, and preoperative CT findings of both the thrombus on the left atrial side and
SC
pannus formation on the LV side were confirmed in the operative findings.
M AN U
Case report
A 69-year-old female who had undergone mitral valve replacement 14 years earlier was admitted to evaluate a prosthetic heart valve (PHV) dysfunction detected on echocardiography. She has been adequately anticoagulated with warfarin recommended by
TE D
guideline. On echocardiography, the medial leaflet of the PHV did not move, and the mean transvalvular pressure gradient was increased to 9 mmHg. Cardiac CT was performed to evaluate the perivalvular abnormality and coronary artery disease. A CT coronal and en face
EP
views of the mitral annular plane 1 showed a low-density, mass-like lesion (white arrow) on the left atrial (LA) side of the PHV (CT density, 35–50 Hounsfield units), which was attached
AC C
to the medial valve strut (Figures 1A). On the left ventricular (LV) side of the PHV, there was a plate like lesion (arrowheads) encircling the outlet of the mitral PHV (Figures 1B). Interestingly, the LV side lesion displayed a relatively high CT density (130–180 Hounsfield units in a non-calcified area) with internal calcified foci (red arrow). This LV side lesion was considered to be the cause of the leaflet motion abnormality (Supplementary Video 1) and thought to be a subvalvular pannus formation. The preoperative CT findings of both thrombus and pannus formation were confirmed in the operative findings (Figures 1C and 1D). 2
ACCEPTED MANUSCRIPT Concurrent valve thrombosis and pannus formation has been reported as a rare occurrence2. Because the initial therapeutic approach to these two diseases may differ, the diagnosis of a valve thrombus and pannus by non-invasive imaging is important. Pannus
RI PT
formation may trigger thrombosis formation, and chronic thrombosis may also predispose a patient to pannus formation2. In a previous study, the pannus showed a relatively high CT density with a rim-like lesion3,4. In contrast, the thrombus displayed a lower CT density with
SC
an amorphous and irregular shape compared to the pannus5.
M AN U
Funding Sources
This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT, & Future
References 1.
TE D
Planning (NRF-2013R1A1A1058711).
Koo HJ, Yang DH, Oh SY, Kang JW, Kim DH, Song JK, Lee JW, Chung CH, Lim TH: Demonstration of mitral valve prolapse with CT for planning of mitral valve repair.
EP
Radiographics : a review publication of the Radiological Society of North America, Inc 2014;34:1537-1552.
Arnaiz-Garcia ME, Gonzalez-Santos JM, Bueno-Codoner ME, Lopez-Rodriguez J,
AC C
2.
Dalmau-Sorli MJ, Arevalo-Abascal A, Arribas-Jimenez A, Diego-Nieto A, RodriguezCollado J, Rodriguez-Lopez JM: Perivalvular pannus and valve thrombosis: Two concurrent mechanisms of mechanical valve prosthesis dysfunction. Revista portuguesa de cardiologia : orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology : an official journal of the Portuguese Society of Cardiology 2015;34:141 e141-143.
3.
Han K, Yang DH, Shin SY, Kim N, Kang JW, Kim DH, Song JM, Kang DH, Song JK, Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW, Lim TH: Subprosthetic Pannus after Aortic Valve Replacement Surgery: Cardiac CT Findings and Clinical Features. 3
ACCEPTED MANUSCRIPT Radiology 2015;276:724-731. 4.
Chung MS, Yang DH, Kim DH, Kang JW, Lim TH: Subvalvular pannus formation causing aortic stenosis in patient with a normal prosthetic aortic valve: computed tomography finding. European heart journal cardiovascular Imaging 2015;16:458. Ueda T, Teshima H, Fukunaga S, Aoyagi S, Tanaka H: Evaluation of prosthetic valve obstruction
on
electrocardiographically
gated
multidetector-row
computed
RI PT
5.
tomography--identification of subprosthetic pannus in the aortic position. Circulation
SC
journal : official journal of the Japanese Circulation Society 2013;77:418-423.
Supplemental Material
M AN U
Legends to supplementary videos
Video 1. Multiphase cardiac computed tomography (CT) showing motion limitation of the medial leaflet, thrombus formation on the left atrial surface, and pannus formation on the left
AC C
EP
TE D
ventricular surface.
4
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
