ABC | Volume 111, Nº3, September 2018

Case Report Silveira et al Partial papillary muscle rupture and early severe obstructive bioprosthetic valve thrombosis Arq Bras Cardiol. 2018; 111(3):430-433 1. Figueras J, AlcaldeO, Barrabe´s JA, Serra V, Alguersuari J, Cortadellas J, et al. Changes in hospital mortality rates in 425 patients with acute ST-elevation myocardial infarctionandcardiacruptureovera30-yearperiod.Circulation. 2008;118(25):2783–9. 2. Bouma W, Wijdh-den Hamer IJ, Koene BM, Kuijprs M, Natour E, Erasmus ME, et al. Long-term survival after mitral valve surgery for post- myocardial infarction papillary muscle rupture. J Cardiothorac Surg. Jan 27 2015;10:11. 3. Czarnecki A, Thakrar A, Fang T, LytwynM, Ahmade R, Pascoe E, et al. Acute severe mitral regurgitation: consideration of papillary muscle architecture. Cardiovasc Ultrasound. Jan 18 2008; 6:5. 4. Sochowski RA, Chan KL, Ascah K, Bedard P. Comparison of accuracy of transesophageal versus transthoracic echocardiography for the detection of mitral valve prolapse with ruptured chordae tendinae (flail mitral leaflet). Am J Cardiol.1991;67(15):1251-5. 5. Havins J, Lick S, Boor P, Arora H, Ahmad M. Real time three-dimensional transesophageal echocardiography in partial posteromedial papillarymuscle rupture. Echocardiography. 2013;30(6):E179-E81. 6. Calvo FE, Figueras J, Cortadellas J, Soler J. Severe mitral regurgitation complicating acute myocardial infarction. Clinical and angiographic differences between patients with and without papillary muscle rupture. Eur Heart J. 1997;18(10):1606–10. 7. Christ G, Siostrzonek P, Maurer G, Baumgartenr H. Partial papillary muscle rupture complicating acute myocardial infarction. Diagnosis by multiplane transoesophageal echocardiography. Eur Heart J. 1995;16(11):1736–8. 8. Oliver JM, Galloge P, Gonzalez A, Dominguez FJ, Gamallo C, Mesa JM. Bioprosthetic mitral valve thrombosis: clinical profile, Transesophageal echocardiographic features, and follow-up after anticoagulant therapy. J Am Soc Echocardiogr. 1996;9(5):691–9. 9. Egbe AC, Pislaru SV, Pellikka PA, Poterucha JT, Schaff HV, Malozewski JJ, et al. Bioprosthetic valve thrombosis versus structural failure: clinical and echocardiographic predictors. J Am Coll Cardiol. 2015;66(21):2285–94. 10. Lengyel M, Fuster V, Keltai M, Roudaut R, Schulte HD, Seward JB, et al. Guidelines for management of left-sided prosthetic valve thrombosis: a role for thrombolytic therapy. Consensus conference on prosthetic valve thrombosis. J Am Coll Cardiol. 1997;30(6):1521–6. References complication. 8 Its diagnosis remains challenging due to a general lack of awareness on this condition. A combination of clinical and echocardiographic features is helpful for diagnosis. Specific predisposing factors to BPVT include low cardiac output, left atrial dilatation, prior history of thromboembolic events, atrial fibrillation and hypercoagulability. New-onset acute heart failure symptoms, progressive dyspnoea, new thromboembolic event and regression of heart failure symptoms with anticoagulation therapy should be considered as flags for this condition. Some echocardiographic features support the diagnosis of BPVT, such as: direct visualisation of valve thrombosis, like the reported case; a 50%mean gradient increase compared with post-operative evaluation; increased cusp thickness (>2 mm), especially on the downstream aspect of the BPV; abnormal leaflet mobility; regression of BPV abnormalities with anticoagulation, usually within 1–3 months of its initiation or reduced leaflet motion in a cardiac CT scan. 8,9 The optimal treatment of BPVT remains a matter of debate. The strategy depends on clinical presentation, patient’s hemodynamic status, presence of BPV obstruction and valve location. Conventional treatment options include surgery, fibrinolysis and anticoagulation, but anticoagulation coupled with surgery remains the mainstay of treatment. 10 Although independence from long term anticoagulation is an advantage of bioprosthetic valve replacement, cases like the one we described highlight the importance of considering this condition even in patients without significant risk factors, who display heart failure symptoms early after valve replacement. Post-operatively, patients must be categorised according to risk, and perhaps long-term anticoagulation should be considered for high risk patients, as well as periodic echocardiographic evaluation of biological prosthetic valves. In both complications described in this case, echocardiographic characterization with 2D/3D images was essential for the establishment of a correct diagnosis and for guiding treatment. This case illustrates two uncommon cardiac mechanical complications, being peculiar their association in the same patient. Despite their distinct pathophysiology, both conditions represent cardiac emergencies requiring a high index of suspicion and an accurate diagnosis. Cardiovascular imaging stands as an extremely valuable supporting technique in a critical-care setting. The precise recognition of the partial papillary muscle rupture (occasionally a missed diagnosis) and the early obstructive bioprosthetic valve thrombosis allowed a prompt and successfully surgical correction of these conditions, with significant impact on patient’s health and recovery. Author contributions Conception and design of the research: Silveira I, Oliveira M; Writing of the manuscript: Silveira I, Oliveira M, Gomes C; Critical revision of the manuscript for intellectual content: Gomes C, Cabral S, Luz A, Torres S. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associatedwith any thesis or dissertationwork. 432