Images in Clinical Medicine

Prosthetic-Valve Dehiscence

Jose Luis Lopez-Campos, M.D., and Gerardo Vieyra-Herrera, M.D.

N Engl J Med 2010; 362:e20February 18, 2010

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Cardiac Catheterization Showing Significant Displacement of the Prosthetic Aortic Valve with Each Heartbeat.

A 33-year-old man with rheumatic heart disease presented with an acute onset of chest pain. Five years earlier, the patient had undergone replacement of the mitral and aortic valves (Bjork–Shiley and ATS Medical, respectively). On physical examination, he had diaphoresis with normal vital signs and without evidence of congestive heart failure, acute aortic regurgitation, or abnormal prosthetic heart sounds. Electrocardiography that was performed 4 hours after the onset of pain showed ST elevation in left-sided leads V₈ and V₉, which was suggestive of inferoposterior myocardial injury (see the Supplementary Appendix). Laboratory evaluation revealed an elevated international normalized ratio (>12; normal range, 2.5 to 3.5), a creatine kinase level of 39 U per liter (normal range, 0 to 150), a creatine kinase MB level of 5.5 U per liter (normal range, 0.6 to 6.3), and a troponin I level of 0.24 ng per milliliter (normal range, 0.01 to 0.03). Cardiac catheterization showed that the prosthetic aortic valve was significantly displaced with each heartbeat (Panels A and B, arrows, and video); no abnormality of the mitral valve was observed. The patient underwent urgent excision and replacement of the dehisced aortic valve, which was found to be infected with Staphylococcus aureus, with associated vasculitis; the mitral valve was not affected. The patient had postoperative mediastinal bleeding and died from irreversible shock 24 hours later.

Jose Luis Lopez-Campos, M.D.
Gerardo Vieyra-Herrera, M.D.
Instituto Nacional de Cardiologia, Ignacio Chavez, Mexico City, Mexico
drlopezcampos@yahoo.com.mx

This article (10.1056/NEJMicm0805989) was updated on October 20, 2010, at NEJM.org.