Episodic circulatory collapse caused by intermittent prosthetic aortic valve dysfunction

An 80-year-old woman with a 20-mm Medtronic Hall (tilting-disc) aortic prosthesis presented with episodes of chest pain associated with circulatory collapse and subsequent rapid spontaneous recovery. A computed tomography angiogram demonstrated no evidence of aortic dissection, pulmonary embolus, or coronary artery disease. A transthoracic echocardiogram demonstrated a well-functioning prosthetic aortic valve. After another inpatient episode, auscultation demonstrated an intermittent absence of the prosthetic second heart sound. A transesophageal echocardiography examination revealed that the aortic valve was intermittently sticking in the open position. During the emergency replacement, the existing valve was noted to have pannus and overlying thrombus, which are rare in this type of valve but can lead to dramatic circulatory collapse when present. This case demonstrates how a diagnosis of intermittent valve dysfunction can prove elusive. It is important, as part of the assessment of mechanical valves, to perform regular, careful auscultation and echocardiographic examination, with emphasis on recording in Doppler or M-mode through the valve at slow sweep speeds for a prolonged period in order to maximize the chance of diagnosing episodic valve dysfunction.