Doppler echocardiographic evaluation of streptokinase lysis of thrombosed right-sided St. Jude Medical valves in patients with congenital heart defects

Fibrinolytic therapy for mechanical pulmonary valve thrombosis

Treatment of prosthetic heart valve thrombosis using intravenous thrombolytics, although an acceptable alternative to surgery, is not complication free, and the literature has a dearth of data on the subject. This study analyzed the results of fibrinolytic treatment (FT) among a single-center group of patients with mechanical pulmonary valve thrombosis. Between 2000 and 2013, 23 consecutive patients with 25 episodes of pulmonary valve thrombosis received FT. The diagnosis of mechanical pulmonary valve thrombosis was established by fluoroscopy and echocardiography. Streptokinase (SK) was used in 24 cases and alteplase in 1 case. The FT was continued a second day for 14 patients (58.3%), a third day for 1 patient, and a fourth day for 1 patient. Echocardiography and fluoroscopy were performed every day until improvement of malfunction was achieved. Of the 23 patients, 19 had complete resolution of hemodynamic abnormalities after FT, 1 had partial resolution, and 2 showed no change. No patient had major complications. Five minor complications were detected, namely, fever, nausea, thrombophlebitis, epistaxi, and pain. Seven patients (30%) experienced recurrence of thrombosis, whereas four patients had surgery (biological pulmonary valve replacement) without re-thrombolytic therapy, one patient was treated with Alteplase, one patient received SK, and one patient received intense anticoagulation using heparin and warfarin. Overall, FT had a success rate of 84%. The results indicate that regardless of the time to pulmonary valve replacement and echocardiographic and fluoroscopic findings, FT was effective in most cases of mechanical pulmonary valve thrombosis. The efficacy increased with second-day thrombolytic therapy. Major complications were not common after lytic therapy for mechanical pulmonary valve thrombosis.

Bleeding and Thrombotic Emergencies in Pediatric Cardiac Intensive Care

Children in the cardiac intensive care unit (CICU) with congenital or acquired heart disease are at risk for hematologic complications, both hemorrhage and thrombosis. The overall incidence of hematologic complications in the CICU is unknown, but risk factors and target groups have been identified where the essential physiologic balance between bleeding and clotting has been disrupted. Although the best management of life-threatening bleeding and clotting is prevention, the cardiac intensivist is often faced with managing life-threatening hematologic events involving patients from within the unit or those who present from outside. Part I of this review deals with the propensity of children with congenital and acquired heart disease to complications of both bleeding and clotting, and includes discussions of perioperative bleeding, thromboses in single-ventricle patients, clotting of Blalock-Taussig shunts and thrombotic complications of mechanical valves. Part II deals with the subject of stroke in children with heart disease. Part III reviews monitoring the effectiveness of anticoagulation and thrombolysis in the CICU. Currently available diagnostics modalities, medications and management strategies are reviewed and future directions discussed.

Mechanical Valve Replacement in Congenital Heart Defects in the Era of International Normalized Ratio Self-Management

As the number of patients with congenital heart defects requiring heart valve replacement increases, the need for durable valve substitutes with good hemodynamic performance and a low incidence of complications becomes more apparent. The use of porcine xenografts is burdened with early fibrocalcific degeneration, whereas the use of mechanical heart valves led to an increased number of thromboembolic events, especially when implanted in the right side of the heart. We report on our experiences implanting bileaflet heart valves in congenital heart defects since the introduction of international normalized ratio (INR) self-management. The data of 68 long-term survivors (33 males, 35 females) who underwent mechanical heart valve replacement in congenital heart defect were reviewed. Patient age at the time of valve replacement ranged from 5 months to 61 years (mean 21 years). Underlying diagnoses were tetralogy of Fallot (n=33), morbus Ebstein (n=4), atrioventricular canal (n=13), truncus arteriosus communis (n=5), transposition of the great arteries (n=10), and congenitally corrected transposition of the great arteries (n=3). In all patients, bileaflet valves were implanted (St. Jude Medical n=40, Carbomedics n=28). Anticoagulation was performed using dicumarol (Marcumar) and INR self-management in all cases. The mean follow-up was 72 months (range 6-132 months; 409 patient-years). Valve thrombosis developed in 3 of 68 patients (4.4%, all three had tetralogy of Fallot, mean age 9.8 years) after a mean follow-up of 3.5 years. In two of these three patients, re-pulmonary valve replacement was necessary, whereas the third patient was treated by thrombolysis. From our experience, we conclude that mechanical heart valve replacement is a good therapy option with a low complication rate for patients with congenital heart defects requiring valve replacement, especially when INR self-management is performed.

Is There a Role for Mechanical Valved Conduits in the Pulmonary Position?

BACKGROUND

The use of allografts or xenografts is the treatment of choice for pulmonary valve replacement. However, the limited durability is responsible for multiple reoperations associated with increased morbidity. In search of a definitive solution, the implantation of a mechanical valved conduit might be an option in highly selected patients. This study evaluated short-term results after pulmonary valve replacement with a mechanical valved conduit.

METHODS

Fourteen patients underwent pulmonary valve replacement with a mechanical valved conduit. All patients had a mean of 3.0 +/- 1.2 previous operations. Seven patients were previously operated on for tetralogy of Fallot, 3 patients for pulmonary atresia, 3 patients for common arterial trunk, and 1 patient for subaortic stenosis.

RESULTS

All patients survived the operation and are currently well. At follow-up (11 to 63 months), all but 2 patients showed normal right ventricular function, with a mean gradient of 14 +/- 9 mm Hg (range, 4 to 30 mm Hg) across the pulmonary valve. At follow-up, there was no evidence of valve failure or tissue growth within the valve annulus. All patients are receiving anticoagulants to maintain an international normalized ratio of 3.0 to 4.5.

CONCLUSIONS

In highly selected patients, the use of a mechanical valved conduit in the pulmonary position leads to satisfactory results. To avoid a predictable reoperation after multiple right ventricular outflow tract reconstruction, and therefore reoperation-related morbidity, the implantation of a mechanical prosthesis as a lifelong solution requires consideration. Selection criteria for this permanent solution should include older age, multiple previous operations, and patient compliance with anticoagulant therapy.

Intra-atrial tissue plasminogen activator infusion for prosthetic valve thrombosis

Thrombosis is a well-known and life-threatening complication of prosthetic mechanical valves. Therapy typically requires medical thrombolysis or surgical thrombectomy/valve replacement. We report the case of a thrombosed atrioventricular valve in a young boy with complex congenital heart disease, which was successfully treated with direct intra-atrial infusion of recombinant tissue plasminogen activator after failed attempts at systemic therapy. We present this treatment as an alternative to conventional medical therapy.

St. Jude medical valve in pulmonary position: anticoagulation and thrombosis

Between 1979 and 1985, 5 patients underwent pulmonary valve replacement with a St. Jude Medical valve. During follow-up ranging from 30 months to 18 years, there were 6 episodes of valve thrombosis in 4 patients. Three episodes were treated by thrombolysis. Reoperation was necessary in 3 patients. Although the St. Jude Medical valve in the pulmonary position can occasionally function long-term without anticoagulation, these cases show the high risk of thrombosis and need for anticoagulation.

Intravenous thrombolytic treatment of mechanical prosthetic valve thrombosis: a study using serial transesophageal echocardiography

OBJECTIVE

We analyzed the results of intravenous thrombolytic treatment under transesophageal echocardiographic (TEE) guidance in prosthetic valve thrombosis.

BACKGROUND

Thrombotic occlusion of prosthetic valves continues to be an uncommon but serious complication. Intravenous thrombolytic treatment has been proposed as an alternative to surgical intervention.

METHODS

In a four-year period, 32 symptomatic patients with prosthetic valve related thrombosis underwent 54 thrombolytic treatment sessions for the treatment of 36 distinct episodes. All patients had low international normalized ratio values at the presentation. Transesophageal echocardiography was performed at baseline and repeated after each thrombolytic treatment session (total 98 TEE examinations). Streptokinase was used as the initial agent with a repeat dose given within 24 h when necessary. Recurrent thrombosis was treated either with tissue plasminogen activator or urokinase.

RESULTS

The initial success after first dose was only 53% (17/32) but increased up to 88% (28/32) after repeated thrombolytic sessions upon documentation of suboptimal results on TEE examination (p < 0.01). In addition, four asymptomatic patients with large thrombi were also successfully treated with single infusion. The TEE characteristics of thrombus correlated with clinical presentation and response to lytics. Success was achieved with single lytic infusion in 40% of the obstructive thrombi as compared with 75% of the nonobstructive ones (p < 0.05). The success rates of lytic treatment were similar for mitral versus aortic valves, and for tilting disk versus bileaflet valves. Rapid (3 h) and slow (15 to 24 h) infusion of streptokinase resulted in similar success rates. However, major complications (three patients) occurred only in the rapid infusion group.

CONCLUSION

In patients with prosthetic valve thrombosis, intravenous slow infusion thrombolysis given in discrete, successive sessions guided by serial TEE and transthoracic echocardiography can be achieved with a low risk of complications and a high rate of success.

Thrombosis of bileaflet tricuspid valve prosthesis: clinical spectrum and the role of nonsurgical treatment

BACKGROUND

Thrombosis of a mechanical tricuspid valve prosthesis is a potentially hazardous event. This study aimed to explore the incidence and the clinical presentation of tricuspid valve thrombosis occurring in bileaflet valves and to evaluate the diagnostic and the therapeutic approach.

METHODS AND RESULTS

Tricuspid valve thrombosis was sought in 22 late survivors with the CarboMedics valve in a follow-up period of 36.0 +/- 20.8 months. Limited leaflet motion and/or a visible thrombus were considered diagnostic of valve thrombosis. Eight episodes of tricuspid valve thrombosis were diagnosed among 5 patients (12.1 episodes per 100 patient-years). Anticoagulation was inadequate in 3 patients and fair in 2. Florid right heart failure occurred in 3 episodes. Common physical findings included increased jugular venous pulse (5 patients), diastolic tricuspid murmur (4 patients), and peripheral edema (4 patients). The diagnosis was suspected in all clinically and by transthoracic echocardiography and confirmed by fluoroscopy and/or transesophageal echocardiography. In 4 patients, both leaflets were involved. No thrombi were visualized. Three patients received thrombolytic therapy in 4 episodes (complete success in 3, partial success in 1) without hemorrhagic or embolic complications. One patient responded to aggressive anticoagulant therapy. One patient required an emergent repeat surgery. In 1 patient, valve thrombosis recurred thrice.

CONCLUSIONS

In patients with fair or poor anticoagulation, a bileaflet valve in the tricuspid position is associated with a high incidence of valve thrombosis. Hinge entrapment requires only a small amount of thrombotic material. Valve thrombosis may be asymptomatic. Involvement of both leaflets is usually required to produce symptoms. A nonsurgical approach (thrombolysis or intensified anticoagulation) is usually successful. Patients should be instructed about heralding signs of valve thrombosis.

Thrombolytic therapy for obstruction of mechanical prosthetic valves

This report describes two patients who were treated for obstruction of St. Jude tricuspid valve prostheses. In the patient with the hypereosinophilic syndrome, right heart failure developed 15 days after valve replacement. The other patient had symptoms of right heart failure for 8 weeks; these occurred 15 months after valve implantation. In both patients, thrombolytic therapy was successful and without major sequelae. Herein we review the literature on the use of thrombolysis for obstructed mechanical prosthetic valves and completely summarize the English literature; the efficacy of thrombolysis for obstructed prosthetic valves and the associated morbidity and mortality are emphasized. Recommendations for thrombolysis in clinical practice are provided.

Thrombolytic therapy in infants and children

Thrombolytic therapy is being increasingly used to treat various cardiac and other disorders in the pediatric population. The use of thrombolytic therapy in thrombosis following cardiac catheterization, aortic thrombosis, right atrial and caval thrombosis, pulmonary embolism, thrombosed prosthetic valves, thrombosed Blalock-Taussig shunts, and other disorders is delineated. Special issues of the newborn are discussed. A wider appreciation of the indications and contemporary experience would help in optimizing the use of thrombolytic therapy in children.

Streptokinase therapy in a five-year-old child with prosthetic mitral valve thrombosis

Intravenous streptokinase therapy for prosthetic valve thrombosis in a 5-year-old child is reported for its rarity. The therapy is safe and effective and as in adults, should be considered the first line of treatment for prosthetic valve thrombosis in children.

Thrombosed prosthetic valve in tricuspid position. Successful therapy with intravenous streptokinase

The successful use of streptokinase therapy in a child with chronic thrombosis of a prosthetic valve (Carbomedics) in the tricuspid position is presented.