Acute prosthetic mitral valve dysfunction due to non-traumatic fracture of prosthesis

Abstract

A 54-year-old man who had prosthetic aortic valve (AV) and mitral valve (MV) (St Jude Medical 19mm of AV and St. Jude Medical 29mm of MV) was referred to the emergency department for acute dyspnoea. Despite mechanical ventilation and administration of vasoactive drug, pulmonary oedema was aggravated and organ perfusion was deteriorated. After applying extracorporeal membrane oxygenation, we started evaluation for unknown shock status. Transthoracic echocardiography showed normal systolic function, elevated mean pressure gradient (PG) across MV (8.6mmHg), and normal mean PG across AV (12.7mmHg). However, it was difficult to evaluate transvalvular regurgitation. On fluoroscopy, only one mobile mitral leaflet was observed (see Supplementary material online, Video S1). Transoesophageal echocardiography revealed extensive mitral regurgitation through the absence of part of prosthesis (Panels A and B, Supplementary material online, Video S2; white arrow in Panel B: absence of one mitral prosthetic valve leaflet). He underwent emergency double valve replacement. Only one mitral leaflet was presented without thrombus or vegetation in the operation field (Panel C). To find the migrating prosthesis, we additionally underwent whole body fluoroscopy. It was detected in the left common femoral artery (Panels E and F; white arrows: migrating leaflet in the left common femoral artery) and surgically removed (Panel D). Fracture of the prosthesis is extremely rare complication in patients with mechanical valves. In this case, fracture and migration of prosthesis was spontaneously and abruptly developed without any triggers such as thrombus, infection, or trauma. Fracture of leaflet leads to serious condition such as acute heart failure and cardiogenic shock associated extremely high mortality. Therefore, it is important to suspect in case of sudden onset prosthetic valve dysfunction.