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A 70 year old man had a Starr-Edward's aortic valve prosthesis inserted in 1970 for aortic stenosis. He presented 29 years later with enterococcus septicaemia, acute renal failure, and cardiac failure requiring ionotropes.
Transoesophageal echocardiography (TOE) showed no evidence of aortic outflow obstruction, valvar incompetence, or a paravalvar leak to explain the gross heart failure. A left heart catheter showed normal coronary arteries. Closer inspection of the movement of the ball within the cage, however, showed it to be skewed and asymmetrical (below left). We suspected the presence of infected debris within the cage and therefore proceeded to surgery on the basis that there was outflow obstruction.
At surgery there was no debris within the cage itself. However half of the undersurface of the valve orifice was occluded (below centre).
Blood was flowing through the patent half and pushing the ball to the other side of the cage (below right). There was therefore a significant outflow obstruction, which explained the patient's cardiac failure and the abnormal movement of the ball at angiography.
The abscess was debrided, the annulus reconstructed with bovine pericardium, and an Edwards Lifesciences perimount valve was inserted. The patient's heart failure resolved postoperatively. He was discharged on day 35.
This case illustrates the limitations of TOE in the management of prosthetic valve endocarditis. It also demonstrates a subtle sign of obstruction in a Starr-Edward's aortic prosthetic valve.
- A subtle sign of aortic outflow obstruction in an infected 29 year old Starr-Edward's valve
E F AKOWUAH, C V P ONYEAKA, G J COOPER
Click here for video clip of angiogram (mpg file approximately 3 Mbytes)