Leaflet escape from a prosthetic valve has been reported following both mitral and aortic valve replacement surgery at variable intervals of time ranging from days to several years after the date of operation [2]. The causes for leaflet escape have been ascribed mainly to pivot system fracture [2, 3] or disc fracture [4] though rarely it can follow interventional cardiological maneuvers as in our case.
The usual mode of presentation is with acute severe shortness of breath, often after a period of activity. Clinically, the picture is of acute left ventricular failure and pulmonary edema with cardiogenic shock, due to severe valvular incompetence [1–4]. Possible differential diagnosis that needs to be ruled out are myocardial infarction, para prosthetic valvular leak, malignant arrhythmia and pulmonary embolism.
Echocardiography is not always diagnostic of the leaflet escape and may be interpreted as showing obstructed closure of the prosthetic valve or a paravalvular leak. The picture can be confusing and misinterpreted as showing valve thrombosis resulting in anticoagulant therapy causing delay in life-saving surgery and death of patient [5].
Timely diagnosis and emergency surgical replacement of the damaged prosthetic valve is indicated. Delay in diagnosis or treatment may prove to be detrimental [2, 5]. It is sometimes difficult to locate the missing leaflet which may have embolised more distally in the aorta [3, 5] or iliac artery [1]. Plain radiographs often fail to visualize the disc as they are not sufficiently radio opaque. Ultrasound and CT scan are more accurate at localizing the dislodged leaflet [6, 7] in most reported cases. Fluoroscopy [5] has also been used in some cases to localize the leaflet.
In the reported literature, it has been considered mandatory to retrieve the embolised disc at the same time or shortly after valve replacement [1]. Rarely the leaflets eluded all attempts at localization and were discovered only at autopsy [5].
There are only few reports of patient achieving long term survival, without complications, with a mechanical valve leaflet lodged in thoracic aorta. This we believe is the case with the longest survival. Previous authors have emphasized that it is mandatory to remove the foreign body due to risk of thrombosis, migration, erosion and infection at the site of lodgment. The critical condition of our patient at presentation along with absence of hemodynamic obstruction prompted us to follow a wait and watch policy against this recommendation, which proved a successful strategy.
