Exceptional Finding of Double Pannus in Aortic and Mitral Mechanical Prosthetic Valves Using Noninvasive Imaging: A Case Report

Figures

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  Figure 1. ECG showing atrial fibrillation with a ventricular rate of 57 beats/min, normal electrical axis, and left ventricular hypertrophy with a strain pattern.

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  Figure 2. Standard chest X-ray showing cardiomegaly predominantly due to left ventricular and left atrial enlargement, with visualization of the mechanical tricuspid prosthesis and median sternotomy wires from previous cardiac surgeries.

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  Figure 3. Fluoroscopic images of the mitral and aortic prosthetic valves. (A) The yellow arrow indicates the restricted leaflet, resulting in incomplete opening of the mechanical mitral valve. (B) The yellow arrow indicates the restricted leaflet, resulting in incomplete opening of the mechanical aortic valve.

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  Figure 4. TTE images showing markedly elevated transprosthetic gradients across both the mitral and aortic prostheses. (A) Color Doppler imaging demonstrating flow acceleration with aliasing at the level of the aortic prosthesis. (B) Continuous-wave Doppler across the aortic prosthetic valve showing a markedly elevated mean gradient of 40 mmHg averaged over multiple cardiac cycles. (C) Color Doppler imaging demonstrating significant flow acceleration with aliasing at the level of the mitral prosthesis. (D) Continuous-wave Doppler across the mitral prosthetic valve showing a markedly elevated mean gradient of 15.2 mmHg averaged over multiple cardiac cycles. TTE, transthoracic echocardiography

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  Figure 5. TEE images showing obstruction of one leaflet of the mechanical mitral prosthesis caused by giant pannus formation. (A) Two-dimensional TEE image demonstrating immobilization of one leaflet of the mechanical mitral valve. (B) Color Doppler imaging showing absence of blood flow through the obstructed leaflet orifice. (C) Continuous-wave Doppler demonstrating an elevated mean transmitral gradient of 11 mmHg averaged over multiple cardiac cycles. (D) Three-dimensional reconstruction illustrating leaflet obstruction caused by giant pannus formation. TEE, transesophageal echocardiography

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  Figure 6. TTE imaging showing a pannus-like mass on the ventricular side of the aortic prosthesis (yellow arrow), associated with marked flow acceleration on color Doppler imaging. TTE, transthoracic echocardiography

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  Figure 7. Cardiac CT of the mechanical valves in the mitral and aortic positions. (A) The red arrow indicates a dense subvalvular pannus located on the ventricular side of the mechanical aortic prosthesis. The lesion appears as a focal fibrous tissue overgrowth extending from the prosthetic ring toward the leaflet, resulting in restricted leaflet motion and prosthetic valve obstruction. (B) The yellow arrow indicates a dense pannus formation adjacent to the lateral aspect of the mitral prosthetic disc. The fibrous tissue extends toward the leaflet and contributes to impaired disc mobility and prosthetic valve obstruction.

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  Figure 8. Intraoperative images of mitral pannus removal. (A) The mechanical mitral prosthesis was covered by a huge pannus surrounding the prosthetic ring (yellow arrow). (B) The mechanical mitral valve is clearly visible after removal of the ventricular-side pannus. (C) Gross appearance of the pannus tissue removed from the ventricular surface of the prosthesis.