After five hours of the surgery, her vital signs were stabilized. TTE after the surgery demonstrated well functioning bioprosthetic mitral valve with decreased tricuspid regurgitation (Grade I) and resolution of pulmonary hypertension (RVSP 39 mmHg). Fig. 3 Edward-Duromedics mitral valve retrieved from the emergent surgery. In an attempt to localize the missing leaflet, computed
tomography (CT) was done, and a plate like metallic density in infra-renal abdominal aorta was noted (Fig. 4). The remaining fragment of leaflet in infra renal abdominal artery Inhibitors,research,lifescience,medical was removed 11 days after bioprosthetic valve replacement. It was placed 2 cm above common iliac artery bifurcation. The abdominal aorta was vertically dissected 7 cm, and the fragment was safely removed (Fig. 5). The patient developed Inhibitors,research,lifescience,medical mild fever after the surgery but recovered well and was discharged 37 days after the surgery. Fig. 4 Computed tomography locating the missing leaflet of the prosthetic valve in infrarenal abdominal aorta. White arrow indicates the missing leaflet. Fig. 5 The remaining fragment of leaflet in infra renal abdominal artery was removed from placed 2 cm above common iliac artery bifurcation. Discussion One of the main concerns for prosthetic valve is its durability for lifelong time. Leaflet escape of bi-leaflet mechanical Inhibitors,research,lifescience,medical prosthesis has been reported (Tekna and Duromedics) to be extremely
rare.1-5) The leaflet escape is reported to happen more frequently in mitral than aortic positions. A few factors have been
reported to account for material deterioration.6) The cavitation, which is the rapid formation Inhibitors,research,lifescience,medical of vaporous microbubbles in a fluid by a local reduction of pressure below the vapor pressure7) is recognized as the most contributing factor to the series of valve failure in Edward-Duromedics prosthesis. The damages by cavitation may lead to pitting and microcracking. Other factors identified are asymmetric closure with local stresses, inadequate compliance of calcified sewing ring, clustered microporosity of the pyrolytic carbon Inhibitors,research,lifescience,medical and surgical mishandling.6) The time of leaflet escape varies from 19 days6) to 12 years8) after the Resminostat implantation of the mitral valve. The clinical presentation is usually acute pulmonary edema with cardiogenic shock as the result of acute valvular incompetence.1-5) Other causes of the clinical symptoms, such as BTK inhibitor myocardiac infarction, para-valvular leak, thrombosis of the prosthetic valves, malignant arrhythmia and pulmonary embolism should be considered. TTE is usually not helpful for the diagnosed as it may be mis-interpretated as obstructed closure of the prosthetic valve, paravalvular leak or thrombosis.9) Transesophageal echocardiography (TEE) is diagnostic most of times. Cineflouroscopy may role as non invasive diagnostic tool to determine leaflet escape from valve thrombosis.9),10) It is acknowledged that timely diagnosis and emergent surgical replacement of the prosthetic valve is most important.