Abstract
Assessment of the left ventricular pressure measured across an aortic valve prosthesis is occasionally necessary when noninvasive imaging and Doppler echocardiographic data are inconclusive or differ from the clinical findings for specific scenarios, such as diagnosing constrictive or restrictive physiology. We present a case in which we safely and effectively replicate the previous successful application of a PressureWire in diagnosing constrictive pericarditis in a patient with a bileafltet mechanical aortic and mitral valves.
1
Introduction
Accurate echocardiographic assessment of mechanical valve function and hemodynamics is challenging. This is further compounded when assessing patients with mechanical valves and suspected constrictive pericarditis. The standard invasive approach to measure left ventricular pressure and valve gradients with a pigtail catheter and 0.038-in. wire in a patient with a mechanical aortic valve is contraindicated; there is a risk of valvular dysfunction that may ultimately prove fatal . Transeptal puncture and antegrade catheterisation of the left ventricle across the mitral valve are not only technically demanding, but also contraindicated in patients with mechanical prosthetic mitral valves. Furthermore, transapical left ventricular puncture is associated with considerable morbidity and mortality . Accordingly, in this complicated case to establish constrictive physiology in the setting of mechanical aortic and mitral prostheses, we measured left ventricular pressure by retrogradely crossing the prosthetic aortic valve with a 0.014-in. PressureWire (St. Jude Medical, St. Paul, MN, USA) with simultaneous right heart catheterisation. The technical feasibility and safety of using the high-fidelity coronary pressure wires to measure transvalvular gradients has been established ; however, the feasibility of assessing for constrictive pericarditis needs further investigation .
2
Case report
A 43-year-old female with radiation-induced cardiomyopathy and subsequent premature ischemic heart disease and valvular heart disease underwent extensive cardiac surgery with coronary grafting, insertion of both mechanical aortic and mitral prostheses, and tricuspid annuloplasty. Subsequently, a biventricular implantable cardioverter-defibrillator was inserted for cardiac dysfunction. Persistent right heart failure symptoms and signs developed approximately 2 months postsurgery, and there was clinical and echocardiographic suspicion of constrictive pericarditis. Transthoracic echocardiogram demonstrated low-normal left ventricular systolic dysfunction and mild-to-moderate right ventricular dysfunction with normal pulmonary pressures. Both the aortic and mitral valve prostheses were functioning satisfactorily. There was evidence of ventricular interdependence manifest as septal bounce. There was progressive thickening of the pericardium on serial computed tomography scans. The patient was ultimately referred for catheterisation with direct hemodynamic assessment to confirm the diagnosis of constriction. We considered use of a 4-Fr multipurpose catheter unjustifiable. Our team elected to use a 0.014-in. PressureWire, used for invasive coronary physiology measurements, to cross the aortic prosthesis and obtain a direct high-fidelity left ventricular pressure measurement as previously described .
2
Case report
A 43-year-old female with radiation-induced cardiomyopathy and subsequent premature ischemic heart disease and valvular heart disease underwent extensive cardiac surgery with coronary grafting, insertion of both mechanical aortic and mitral prostheses, and tricuspid annuloplasty. Subsequently, a biventricular implantable cardioverter-defibrillator was inserted for cardiac dysfunction. Persistent right heart failure symptoms and signs developed approximately 2 months postsurgery, and there was clinical and echocardiographic suspicion of constrictive pericarditis. Transthoracic echocardiogram demonstrated low-normal left ventricular systolic dysfunction and mild-to-moderate right ventricular dysfunction with normal pulmonary pressures. Both the aortic and mitral valve prostheses were functioning satisfactorily. There was evidence of ventricular interdependence manifest as septal bounce. There was progressive thickening of the pericardium on serial computed tomography scans. The patient was ultimately referred for catheterisation with direct hemodynamic assessment to confirm the diagnosis of constriction. We considered use of a 4-Fr multipurpose catheter unjustifiable. Our team elected to use a 0.014-in. PressureWire, used for invasive coronary physiology measurements, to cross the aortic prosthesis and obtain a direct high-fidelity left ventricular pressure measurement as previously described .
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