Clinical Research in Cardiology

, Volume 107, Issue 7, pp 554–564 | Cite as

Impact of pannus formation on hemodynamic dysfunction of prosthetic aortic valve: pannus extent and its relationship to prosthetic valve motion and degree of stenosis

  • Hyun Jung Koo
  • Hojin Ha
  • Joon-Won Kang
  • Jeong A. Kim
  • Jae-Kwan Song
  • Hwa Jung Kim
  • Tae-Hwan Lim
  • Dong Hyun Yang
Original Paper



Although pannus is an important cause of prosthetic valve dysfunction, the minimum pannus size that can induce hemodynamic dysfunction has not yet been determined. This study investigated the correlation between the limitation of motion (LOM) of the prosthetic valve and pannus extent and determined the pannus extent that could induce severe aortic stenosis.


This study included 49 patients who underwent mechanical aortic valve replacement (AVR) and showed pannus on cardiac computed tomography (CT). Pannus width, ratio of pannus width to valve diameter, pannus area, effective orifice area, encroachment ratio by pannus, pannus involvement angle and percent LOM of mechanical valves were evaluated on CT. Transvalvular peak velocity (TPV) and transvalvular pressure gradient (TPG) were measured by transesophageal echocardiography to determine the degree of aortic stenosis. The relationship between percent LOM of the prosthetic valve and pannus extent and the cut-off of pannus extent required to induce severe aortic stenosis were evaluated.


The mean interval between AVR and pannus formation was 11 years and was longer in patients with than without severe aortic stenosis (14.0 vs. 7.3 years). On CT, the percent LOM of the prosthetic valve was significantly associated with the extent of pannus only in patients with pannus involvement angle > 180° (r = 0.55–0.68, P < 0.01). Pannus width, effective orifice area, and encroachment ratio were significantly associated with increased TPV and TPG (r = 0.51–0.62, P < 0.01). Pannus width > 3.5 mm, pannus width/valve inner diameter > 0.15, and encroachment ratio > 0.14 were significantly associated with severe aortic stenosis (TPV > 4 m/s; mean TPG ≥ 35 mmHg), with c-indices of 0.74–079 (P < 0.005).


CT-derived pannus extent parameters are good indicators of significant hemodynamic changes with increased TPV and mean TPG.


Pannus Aortic valve replacement Mechanical valve Computed tomography 



This work was supported by National Research Foundation of Korea (NRF) Grants funded by the Korean government (MSIP) (NRF-2016R1A1A1A05921207 and NRF-2015R1A2A2A04003034) and by a grant (2017–7208) from the Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea. This work was also funded by the Industrial Strategic Technology Development Program (10072064) of the Ministry of Trade Industry and Energy of Korea.

Author contributions

All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

Compliance with ethical standards

Conflict of interest

Authors declare that they have no conflict of interest.

Supplementary material

392_2018_1217_MOESM1_ESM.docx (401 kb)
Supplementary material 1 (DOCX 401 KB)
392_2018_1217_MOESM2_ESM.xlsx (20 kb)
Supplementary material 2 (XLSX 19 KB)


  1. 1.
    Chung MS, Yang DH, Kim D-H, Kang J-W, Lim T-H (2015) Subvalvular pannus formation causing aortic stenosis in patient with a normal prosthetic aortic valve: computed tomography finding. Eur Heart J Cardiovasc Imaging 16:458–458CrossRefPubMedGoogle Scholar
  2. 2.
    Han K, Yang DH, Shin SY et al (2015) Subprosthetic pannus after aortic valve replacement surgery: cardiac CT findings and clinical features. Radiology 276:724–731CrossRefPubMedGoogle Scholar
  3. 3.
    Kim GH, Yang DH, Kang J-W, Kim D-H, Jung S-H, Lim T-H (2016) Subvalvular pannus and thrombosis in a mitral valve prosthesis. J Cardiovasc Comput Tomogr 10:191–192CrossRefPubMedGoogle Scholar
  4. 4.
    Suh YJ, Lee S, Im DJ et al (2016) Added value of cardiac computed tomography for evaluation of mechanical aortic valve: Emphasis on evaluation of pannus with surgical findings as standard reference. Int J Cardiol 214:454–460CrossRefPubMedGoogle Scholar
  5. 5.
    Girard SE, Miller FA Jr, Orszulak TA et al (2001) Reoperation for prosthetic aortic valve obstruction in the era of echocardiography: trends in diagnostic testing and comparison with surgical findings. J Am Coll Cardiol 37:579–584CrossRefPubMedGoogle Scholar
  6. 6.
    Ueda T, Teshima H, Fukunaga S, Aoyagi S, Tanaka H (2013) Evaluation of prosthetic valve obstruction on electrocardiographically gated multidetector-row computed tomography—identification of subprosthetic pannus in the aortic position. Circ J 77:418–423CrossRefPubMedGoogle Scholar
  7. 7.
    Anwar AM, Nosir YF, Alasnag M, Chamsi-Pasha H (2014) Real time three-dimensional transesophageal echocardiography: a novel approach for the assessment of prosthetic heart valves. Echocardiography 31:188–196CrossRefPubMedGoogle Scholar
  8. 8.
    Otto CM (2013) Textbook of clinical echocardiography. Elsevier, AmsterdamGoogle Scholar
  9. 9.
    Pibarot P, Dumesnil JG (2012) Low-flow, low-gradient aortic stenosis with normal and depressed left ventricular ejection fraction. J Am Coll Cardiol 60:1845–1853CrossRefPubMedGoogle Scholar
  10. 10.
    Gündüz S, Özkan M, Kalçik M et al (2015) Sixty-four–section cardiac computed tomography in mechanical prosthetic heart valve dysfunction CLINICAL PERSPECTIVE. Circ Cardiovasc Imaging 8:e003246CrossRefPubMedGoogle Scholar
  11. 11.
    LaBounty TM, Agarwal PP, Chughtai A, Bach DS, Wizauer E, Kazerooni EA (2009) Evaluation of mechanical heart valve size and function with ECG-gated 64-MDCT. AJR Am J Roentgenol 193:W389-396CrossRefGoogle Scholar
  12. 12.
    Lee DH, Youn HJ, Shim SB et al (2009) The measurement of opening angle and orifice area of a bileaflet mechanical valve using multidetector computed tomography. Korean Circ J 39:157–162CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Kassi M, Garg N, Chang SM (2013) Utility of cardiac computed tomography for assessment of prosthetic aortic valve dysfunction with pannus formation. Methodist Debakey Cardiovasc J 9:174–175CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Symersky P, Budde RP, de Mol BA, Prokop M (2009) Comparison of multidetector-row computed tomography to echocardiography and fluoroscopy for evaluation of patients with mechanical prosthetic valve obstruction. Am J Cardiol 104:1128–1134CrossRefPubMedGoogle Scholar
  15. 15.
    Teshima H, Hayashida N, Enomoto N, Aoyagi S, Okuda K, Uchida M (2003) Detection of pannus by multidetector-row computed tomography. Ann Thorac Surg 75:1631–1633CrossRefPubMedGoogle Scholar
  16. 16.
    Teshima H, Hayashida N, Fukunaga S et al (2004) Usefulness of a multidetector-row computed tomography scanner for detecting pannus formation. Ann Thorac Surg 77:523–526CrossRefPubMedGoogle Scholar
  17. 17.
    Toledano D, Acar C (2010) Usefulness of computed tomography scanning in the diagnosis of aortic prosthetic valve pannus. J Heart Valve Dis 19:665–668PubMedGoogle Scholar
  18. 18.
    Suh YJ, Kim YJ, Hong YJ et al (2015) Measurement of opening and closing angles of aortic valve prostheses in vivo using dual-source computed tomography: comparison with those of manufacturers’ in 10 different types. Korean J Radiol 16:1012–1023CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Suh YJ, Kim YJ, Lee S et al (2015) Utility of cardiac computed tomography for evaluation of pannus in mechanical aortic valve. Int J Cardiovasc Imaging 31:1271–1280CrossRefPubMedGoogle Scholar
  20. 20.
    Aoyagi S, Fukunaga S, Suzuki S, Nishi Y, Oryoji A, Kosuga K (1996) Obstruction of mechanical valve prostheses: clinical diagnosis and surgical or nonsurgical treatment. Surg Today 26:400–406CrossRefPubMedGoogle Scholar
  21. 21.
    Tsai IC, Lin YK, Chang Y et al (2009) Correctness of multi-detector-row computed tomography for diagnosing mechanical prosthetic heart valve disorders using operative findings as a gold standard. Eur Radiol 19:857–867CrossRefPubMedGoogle Scholar
  22. 22.
    Zoghbi WA, Chambers JB, Dumesnil JG et al (2009) Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography’s Guidelines and Standards Committee and the Task Force on prosthetic valves, developed in conjunction with the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography. J Am Soc Echocardiogr 22:975–1014CrossRefPubMedGoogle Scholar
  23. 23.
    Nagueh SF, Smiseth OA, Appleton CP et al (2016) Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 29:277–314CrossRefPubMedGoogle Scholar
  24. 24.
    Bleiziffer S, Bosmans J, Brecker S et al (2017) Insights on mid-term TAVR performance: 3-year clinical and echocardiographic results from the CoreValve ADVANCE study. Clin Res Cardiol 106:784–795CrossRefPubMedGoogle Scholar
  25. 25.
    Doenst T, Essa Y, Jacoub K et al (2017) Cardiac surgery 2016 reviewed. Clin Res Cardiol 106:851–867CrossRefPubMedGoogle Scholar
  26. 26.
    Mollmann H, Bestehorn K, Bestehorn K M et al (2016) In-hospital outcome of transcatheter vs. surgical aortic valve replacement in patients with aortic valve stenosis: complete dataset of patients treated in 2013 in Germany. Clin Res Cardiol 105:553–559CrossRefPubMedGoogle Scholar
  27. 27.
    Frerker C, Bestehorn K, Schluter M et al (2017) In-hospital mortality in propensity-score matched low-risk patients undergoing routine isolated surgical or transfemoral transcatheter aortic valve replacement in 2014 in Germany. Clin Res Cardiol 106:610–617CrossRefPubMedGoogle Scholar
  28. 28.
    Gaede L, Blumenstein J, Kim WK et al (2017) Trends in aortic valve replacement in Germany in 2015: transcatheter versus isolated surgical aortic valve repair. Clin Res Cardiol 106:411–419CrossRefPubMedGoogle Scholar
  29. 29.
    Aggeli C, Felekos I, Kastellanos S et al (2015) Real-time three-dimensional echocardiography: never before clinical efficacy looked so picturesque. Int J Cardiol 198:15–21CrossRefPubMedGoogle Scholar
  30. 30.
    Tanis W, Teske AJ, van Herwerden LA et al (2015) The additional value of three-dimensional transesophageal echocardiography in complex aortic prosthetic heart valve endocarditis. Echocardiography 32:114–125CrossRefPubMedGoogle Scholar
  31. 31.
    Ellensen VS, Andersen KS, Vitale N, Davidsen ES, Segadal L, Haaverstad R (2013) Acute obstruction by pannus in patients with aortic medtronic-hall valves: 30 years of experience. Ann Thorac Surg 96:2123–2128CrossRefPubMedGoogle Scholar
  32. 32.
    Barbetseas J, Nagueh SF, Pitsavos C, Toutouzas PK, Quiñones MA, Zoghbi WA (1998) Differentiating thrombus from pannus formation in obstructed mechanical prosthetic valves: an evaluation of clinical, transthoracic and transesophageal echocardiographic parameters. J Am Coll Cardiol 32:1410–1417CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Hyun Jung Koo
    • 1
  • Hojin Ha
    • 2
  • Joon-Won Kang
    • 1
  • Jeong A. Kim
    • 3
  • Jae-Kwan Song
    • 4
  • Hwa Jung Kim
    • 5
  • Tae-Hwan Lim
    • 1
  • Dong Hyun Yang
    • 1
    • 6
  1. 1.Department of Radiology, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea
  2. 2.Department of Mechanical and Biomedical EngineeringKangwon National UniversityChuncheonRepublic of Korea
  3. 3.Department of Radiology, Ilsan Paik HospitalInje University College of MedicineGoyangRepublic of Korea
  4. 4.Department of Cardiology, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea
  5. 5.Department of Clinical Epidemiology and Biostatistics, Cancer Center, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea
  6. 6.Department of Radiology and Research Institute of Radiology, Cardiac Imaging Center, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea

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