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Sadeghi R, Ahmadzadeh K, Sarveazad A, Haji Aghajani M, Forouzannia SA, Yarahmadi P. Comparison between surgery and fibrinolytic therapy in prosthetic valve thrombosis: A systematic review and meta-analysis. J Card Surg 2022; 37:2776-2785. [PMID: 35701901 DOI: 10.1111/jocs.16681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/04/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prosthetic valve thrombosis (PVT) is a rare but life-threatening complication. Surgery and fibrinolytic therapy (FT) are the two main treatment options for PVT. The choice between surgery and FT has always been a matter of debate. Previous studies have shown that although the mortality rate is higher in surgery, complications are less frequent than in FT. We aimed to perform a systematic review and meta-analysis to compare the results of surgery and FT in PVT. METHODS A systematic review of the literature was performed through Medline, Embase, Scopus, and Web of Science, encompassing all studies comparing surgery and FT in PVT. The rate of each complication and risk ratio (RR) of complications in surgery and FT were assessed using random-effects models. RESULTS Fifteen studies with 1235 patients were included in the meta-analysis. The pooled risk of the mortality was not significantly different between FT and surgery in patients with PVT (pooled RR = 0.78, 95% confidence interval [CI]: 0.38-1.60, I² = 61.4%). The pooled risks of thromboembolic events (pooled RR = 4.70, 95% CI: 1.83-12.07, I² = 49.6%) and major bleeding (pooled RR = 2.45, 95% CI: 1.09-5.50, I² = 41.1%) and PVT recurrence (pooled RR = 2.06 95% CI: 1.29-3.27, I² = 0.0%) were significantly higher in patients who received FT. CONCLUSION Surgery may be safer and with fewer complications than FT for PVT treatment. However, randomized clinical trials are needed to determine the proper treatment for PVT.
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Affiliation(s)
- Roxana Sadeghi
- Department of Cardiology, Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Koohyar Ahmadzadeh
- Department of Physiology, Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Arash Sarveazad
- Department of Gastroenterology, Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran.,Deparment of Anatomy, Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Haji Aghajani
- Department of Cardiology, Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed A Forouzannia
- Department of Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pourya Yarahmadi
- Department of Medicine, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Effectiveness of alteplase infusion for the management of prosthetic mitral valve thrombosis in paediatric age group and proposed algorithm. Cardiol Young 2022; 33:747-753. [PMID: 35656568 DOI: 10.1017/s1047951122001652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The incidence of prosthetic valve implantation is increasing in the paediatric population. Prosthetic valve thrombosis leading to obstruction could potentially be a life-threatening complication. There is a debate regarding optimal management of this complication, and there is limited use of thrombolytic therapy in childhood in the setting of valve thrombosis. OBJECTIVE We aim to share our experience of successfully using fibrinolytic therapy in terms of alteplase for paediatric prosthetic mitral valve thrombosis and to propose a management algorithm. METHODS This retrospective analysis of the database was conducted at our hospital including patients who underwent thrombolysis (alteplase) for prosthetic mitral valve thrombosis from June, 2011 to June, 2021. A total of 10 patients with 20 attempts of alteplase infusion were found in our record. RESULTS Alteplase was successful in 19 attempts to relieve valve thrombosis. The safe and effective dose of alteplase was between 0.1 and 0.3 mg/kg/hour. There were no associated major bleeding complications and alteplase was administered either by central or peripheral line. CONCLUSION Thrombolysis by alteplase infusion was found to be successful in relief of prosthetic mitral valve thrombosis in paediatric population without major bleeding complications.
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Vitale N, Acquaviva T, Quagliara TP, Di Bari N, Capone G, Marraudino N, Milano AD. Left Ventricular Assist Device Thrombosis: Combined Approach by Echocardiography and Logfiles Review for Diagnosis and Management. Braz J Cardiovasc Surg 2022; 37:145-152. [PMID: 35503697 PMCID: PMC9054159 DOI: 10.21470/1678-9741-2021-0139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction Left ventricular assist devices are an established therapy for end-stage heart failure. Follow-up of these patients showed complications, such as thrombosis. Our objective was to evaluate the contribution of echocardiography — in association with HeartWare HVAD online logfiles reviews and lactate dehydrogenase titration — for diagnosis and treatment of thrombosis. Methods Seventeen episodes of thrombosis were diagnosed in 8/20 patients with HVAD. Diagnosis was made by trans-thoracic echocardiographic blood flow velocities, logfiles review of power consumption and pump flows, and titration of lactate dehydrogenase. Data were collected at baseline routine control (Group A), during thrombosis (Group B), after thrombolysis (Group C). Results Thrombolysis was successful in all cases; one patient died of cerebral haemorrhage. Echocardiographic maximal blood flow velocity near the inflow cannula was 598±42 cm/sec (Group B), 379.41±21 cm/sec (Group C), and 378.24±28 cm/sec (Group A) (P<0.00001). In eight (47%) cases, thrombi were visualized in the left ventricle by three-dimensional modality. Logfiles recordings of blood flows were 9.52±0.9 L/min (Group B), 4.02±0.4 L/min (Group C), and 4.04±0.4 L/min (Group A) (P<00001). Power consumption was 5.01±0.7 W (Group B), 3.45±0.2 W (Group C), and 3.46±0.2 W (Group A) (P<0.00001). Lactate dehydrogenase was 756±54 IU (Group B), 234±22 IU (Group A), and 257±36 IU (Group C) (P<0.00001). Conclusions Echocardiography of increased maximal velocity near the inflow cannula is a sign of HVAD obstruction. Logfile reviews provide a clear picture of HVAD obstruction. Combination of echocardiographic data and review of logfiles detects signs of left ventricular assist devices thrombosis leading to a successful treatment.
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Affiliation(s)
- Nicola Vitale
- Division of Cardiac Surgery, Department of Emergency and Organ Transplantation, Policlinico Hospital, University of Bari, Bari, Italy
| | - Tommaso Acquaviva
- Division of Cardiac Surgery, Department of Emergency and Organ Transplantation, Policlinico Hospital, University of Bari, Bari, Italy
| | - Teresa Paola Quagliara
- Division of Cardiac Surgery, Department of Emergency and Organ Transplantation, Policlinico Hospital, University of Bari, Bari, Italy
| | - Nicola Di Bari
- Division of Cardiac Surgery, Department of Emergency and Organ Transplantation, Policlinico Hospital, University of Bari, Bari, Italy
| | - Giuseppe Capone
- Division of Cardiac Surgery, Department of Emergency and Organ Transplantation, Policlinico Hospital, University of Bari, Bari, Italy
| | - Nicola Marraudino
- Division of Cardiac Surgery, Department of Emergency and Organ Transplantation, Policlinico Hospital, University of Bari, Bari, Italy
| | - Aldo Domenico Milano
- Division of Cardiac Surgery, Department of Emergency and Organ Transplantation, Policlinico Hospital, University of Bari, Bari, Italy
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Zeng J, Wei W. Anesthetic management for patient with severe cyanosis following bioprosthetic valve stenosis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 30446210 PMCID: PMC9391707 DOI: 10.1016/j.bjane.2018.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We presented a 39-year-old female patient with life-threatening hypoxemia after tricuspid valve replacement because of Ebstein's anomaly. And the severe cyanosis is due to bioprosthetic valve stenosis and atrial septal defect. Anesthetic management of a patient with severe obstructive prosthetic valve dysfunction can be challenging. Similar considerations should be given to patients with Ebstein's anomaly to maintain the pressure equalized between the right and left atrial. Transesophageal echocardiography and cerebral oxygen saturation provided real time information in perioperative care.
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Zeng J, Wei W. [Anesthetic management for patient with severe cyanosis following bioprosthetic valve stenosis]. Rev Bras Anestesiol 2018; 69:211-213. [PMID: 30446210 DOI: 10.1016/j.bjan.2018.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 06/17/2018] [Accepted: 06/23/2018] [Indexed: 02/05/2023] Open
Abstract
We presented a 39-year-old female patient with life-threatening hypoxemia after tricuspid valve replacement because of Ebstein's anomaly. And the severe cyanosis is due to bioprosthetic valve stenosis and atrial septal defect. Anesthetic management of a patient with severe obstructive prosthetic valve dysfunction can be challenging. Similar considerations should be given to patients with Ebstein's anomaly to maintain the pressure equalized between the right and left atrial. Transesophageal echocardiography and cerebral oxygen saturation provided real time information in perioperative care.
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Affiliation(s)
- Jun Zeng
- Sichuan University, West China Hospital, Department of Anesthesiology, Chengdu, China
| | - Wei Wei
- Sichuan University, West China Hospital, Department of Anesthesiology, Chengdu, China.
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Bade AS, Shaikh SSA, Khemani H, Singh G, Bansal NO. Thrombolysis Is an Effective and Safe Therapy in Stuck Mitral Valves With Delayed Presentation as Well as Hemodynamically Unstable Patients: A Single Centre Study. Cardiol Res 2018; 9:161-164. [PMID: 29904451 PMCID: PMC5997445 DOI: 10.14740/cr708w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 04/17/2018] [Indexed: 11/18/2022] Open
Abstract
Background Thrombosis is a complication of prosthetic valves on oral anticoagulants which is associated with significant morbidity and mortality. A re-operation carries a substantial risk, with mortality rate from 10% to 15% in selected series, which may be 2- or 3-folds higher in critically ill patients. This study conducted in a tertiary care cardiology unit aimed to evaluate the effectiveness and safety of thrombolytic therapy in stuck mitral bileaflet heart valves. Methods As a prospective observational study, clinical symptoms and fluoroscopy were the mainstay in diagnosis of stuck mitral valve. Gradient across the valve by transthoracic echocardiography was used to monitor the therapy every 6 h. Fall of mean gradient more than 50% was considered as successful thrombolysis. And final results were again checked by fluoroscopy with documentation of improved leaflet movement. Results Totally we studied 34 patients. Patients receiving thrombolytic therapy with streptokinase achieved an overall 91.2% freedom from a repeat operation or major complications, a large subcutaneous hematoma occurred in one ( 2.9%), reoperation required in two due to failure of treatment (5.9%), allergic reaction in one (2.9%), one patient developed transient neurologic dysfunction (2.9%) and one patient died during therapy due to refractory cardiogenic shock(2.9%). All patients including those with delayed presentation (> 14 days) and hemodynamically unstable patients had good results similar to those who presented within 14 days and hemodynamically stable. Mortality was higher in unstable patients and reoperation was higher with delayed presentation. Conclusions Thrombolysis with streptokinase is highly successful and safe therapy in hemodynamically stable as well as unstable patients, or those with early or delayed presentation with stuck bileaflet mitral valves, especially in centers where round the clock cardiothoracic surgery backup is not available.
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Affiliation(s)
- Arun Shivajirao Bade
- Department of Cardiology, Grant Medical College and Sir JJ Group of Hospitals, Mumbai India
| | | | - Hemant Khemani
- Department of Cardiology, Grant Medical College and Sir JJ Group of Hospitals, Mumbai India
| | - Gurkirat Singh
- Department of Cardiology, Grant Medical College and Sir JJ Group of Hospitals, Mumbai India
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Ma WG, Hou B, Abdurusul A, Gong DX, Tang Y, Chang Q, Xu JP, Sun HS. Dysfunction of mechanical heart valve prosthesis: experience with surgical management in 48 patients. J Thorac Dis 2016; 7:2321-9. [PMID: 26793354 DOI: 10.3978/j.issn.2072-1439.2015.12.25] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Dysfunction of mechanical heart valve prostheses is an unusual but potentially lethal complication after mechanical prosthetic valve replacement. We seek to report our experience with mechanical valve dysfunction regarding etiology, surgical techniques and early outcomes. METHODS Clinical data of 48 patients with mechanical valve dysfunction surgically treated between October 1996 and June 2011 were analyzed. RESULTS Mean age was 43.7±10.9 years and 34 were female (70.8%). The median interval from primary valve implantation to dysfunction was 44.5 months (range, 1 hour to 20 years). There were 21 emergent and 27 elective reoperations. The etiology was thrombosis in 19 cases (39.6%), pannus in 12 (25%), thrombosis and pannus in 11 (22.9%), improper disc orientation in 2 (4.1%), missing leaflet in 1 (2.1%), excessively long knot end in 1 (2.1%), endogenous factor in 1 (2.1%) and unidentified in 1 (2.1%). Surgical procedure was mechanical valve replacement in 37 cases (77.1%), bioprosthetic valve replacement in 7 (14.9%), disc rotation in 2 (4.2%) and excision of excessive knot end in 1 (2.1%). Early deaths occurred in 7 patients (14.6%), due to low cardiac output in 3 (6.3%), multi-organ failure in 2 (4.2%) and refractory ventricular fibrillation in 2 (4.2%). Complications occurred in 10 patients (20.8%). CONCLUSIONS Surgical management of mechanical valve dysfunction is associated with significant mortality and morbidity. Earlier identification and prompt reoperation are vital to achieving better clinical outcomes. The high incidence of thrombosis in this series highlights the need for adequate anticoagulation and regular follow-up after mechanical valve replacement.
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Affiliation(s)
- Wei-Guo Ma
- 1 Department of Cardiovascular Surgery, Fu Wai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China ; 2 Department of Cardiothoracic Surgery, First Hospital of Kashgar Prefecture, Shinjang 844000, China
| | - Bin Hou
- 1 Department of Cardiovascular Surgery, Fu Wai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China ; 2 Department of Cardiothoracic Surgery, First Hospital of Kashgar Prefecture, Shinjang 844000, China
| | - Adiljan Abdurusul
- 1 Department of Cardiovascular Surgery, Fu Wai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China ; 2 Department of Cardiothoracic Surgery, First Hospital of Kashgar Prefecture, Shinjang 844000, China
| | - Ding-Xu Gong
- 1 Department of Cardiovascular Surgery, Fu Wai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China ; 2 Department of Cardiothoracic Surgery, First Hospital of Kashgar Prefecture, Shinjang 844000, China
| | - Yue Tang
- 1 Department of Cardiovascular Surgery, Fu Wai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China ; 2 Department of Cardiothoracic Surgery, First Hospital of Kashgar Prefecture, Shinjang 844000, China
| | - Qian Chang
- 1 Department of Cardiovascular Surgery, Fu Wai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China ; 2 Department of Cardiothoracic Surgery, First Hospital of Kashgar Prefecture, Shinjang 844000, China
| | - Jian-Ping Xu
- 1 Department of Cardiovascular Surgery, Fu Wai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China ; 2 Department of Cardiothoracic Surgery, First Hospital of Kashgar Prefecture, Shinjang 844000, China
| | - Han-Song Sun
- 1 Department of Cardiovascular Surgery, Fu Wai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China ; 2 Department of Cardiothoracic Surgery, First Hospital of Kashgar Prefecture, Shinjang 844000, China
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Fibrinolytic therapy for mechanical pulmonary valve thrombosis. Pediatr Cardiol 2015; 36:171-6. [PMID: 25145294 DOI: 10.1007/s00246-014-0982-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 07/22/2014] [Indexed: 10/24/2022]
Abstract
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.
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Cáceres-Lóriga FM, Pérez-López H, Morlans-Hernández K, Facundo-Sánchez H, Santos-Gracia J, Valiente-Mustelier J, Rodiles-Aldana F, Marrero-Mirayaga MA, Betancourt BY, López-Saura P. Thrombolysis as first choice therapy in prosthetic heart valve thrombosis. A study of 68 patients. J Thromb Thrombolysis 2014; 21:185-90. [PMID: 16622616 DOI: 10.1007/s11239-006-4969-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Valvular thrombosis is a serious complication in patients with prosthetic heart valves. Traditional treatment is emergency surgery, but thrombolysis provides a non invasive alternative. In this paper we evaluate the efficacy and safety of thrombolysis in prosthetic heart valve thrombosis. METHODS Data of 68 patients diagnosed of prosthetic valve thrombosis, treated at the Institute of Cardiology and Cardiovascular Surgery, Havana during a 6-years period were analyzed. They received thrombolysis with a recombinant streptokinase infusion at 250,000 IU in 30 minutes followed by 100,000 IU/hour during 72 hours or less if the thrombosis resolved before. The evaluation was based on clinical and echocardiographic findings. RESULTS Affected sites were mitral (50 cases), tricuspid (9), and aortic (9). Mean time of prosthesis implantation was 6.8 years. The presentation form was generally heart failure (NYHA functional class III-IV) in 64 (94.1%) patients. Mean time interval between onset of symptoms and diagnosis was 10.6 days. There was total response to treatment in 58 (85.3%) patients, partial in 4 (5.9%) and failure in 6 (8.8%). Recombinant streptokinase overall dose was 5.1 x 10(6) IU and mean infusion time 50 hours. Major hemorrhagic complications were observed in two patients. Five embolic events occurred during thrombolysis. Four patients died. Rethrombosis was noted in 11 patients; 10 were retreated successfully with thrombolysis. CONCLUSIONS Thrombolysis with recombinant streptokinase is efficacious and safe for the treatment of prosthetic heart valve thrombosis. It does not contraindicate surgical treatment if there is no total response, because patient goes to surgery in better hemodynamic conditions with lower risk. Nowadays it can be considered as first-line treatment in all patients with prosthetic heart valve thrombosis regardless of functional class unless specific contraindications exist.
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Giglia TM, Massicotte MP, Tweddell JS, Barst RJ, Bauman M, Erickson CC, Feltes TF, Foster E, Hinoki K, Ichord RN, Kreutzer J, McCrindle BW, Newburger JW, Tabbutt S, Todd JL, Webb CL. Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease. Circulation 2013; 128:2622-703. [DOI: 10.1161/01.cir.0000436140.77832.7a] [Citation(s) in RCA: 202] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Giglia TM, DiNardo J, Ghanayem NS, Ichord R, Niebler RA, Odegard KC, Massicotte MP, Yates AR, Laussen PC, Tweddell JS. Bleeding and Thrombotic Emergencies in Pediatric Cardiac Intensive Care. World J Pediatr Congenit Heart Surg 2012; 3:470-91. [DOI: 10.1177/2150135112460866] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Therese M. Giglia
- Division of Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - James DiNardo
- Division of Cardiac Anesthesia, Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nancy S. Ghanayem
- Division of Critical Care, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Rebecca Ichord
- Division of Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Robert A. Niebler
- Division of Critical Care, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Kirsten C. Odegard
- Division of Cardiovascular Critical Care, Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - M. Patricia Massicotte
- Department of Pediatrics, Stoller Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew R. Yates
- Sections of Cardiology and Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Peter C. Laussen
- Division of Cardiovascular Critical Care, Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - James S. Tweddell
- Division of Critical Care, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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Yay K, Boysan E, Irdem A, Cetin E, Altinay L, Tutun U, Cicekcioglu F, Katircioglu SF. Treatment of Mechanical Aortic Valve Thrombosis Fibrinolytic Treatment versus Surgical Intervention: Result of Eight Cases. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2010; 5:439-43. [DOI: 10.1177/155698451000500610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Thrombosis of mechanical heart valve prosthesis is a rare fatal complication after heart valve replacement. Although surgical intervention is the suggested treatment in many series, fibrinolytic treatment offers a good alternative. We describe eight cases with mechanical aortic valve thrombosis and compare their results after fibrinolytic treatment or redo aortic valve replacement. Methods Between February 2008 and March 2009, eight patients with previous mechanical prosthetic aortic valve replacement history were admitted to our center with mechanical aortic valve thrombosis. Four patients were operated, and the remaining four patients received low-dose fibrinolytic treatment. All patients’ data were collected prospectively. Results Two of the four operated patients died. In the fibrinolytic group, all patients totally recovered, and there was no mortality or morbidity during the follow-up period. Conclusions We thought that fibrinolytic treatment is a feasible and effective method for thrombosed mechanical aortic valve. However, much more populated patient groups are needed for the vigorous inference.
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Affiliation(s)
- Kerem Yay
- Department of Cardiovascular Surgery, Türkiye Yüksek &Idott;htisas Hospital, Ankara, Turkey
| | - Emre Boysan
- Department of Cardiovascular Surgery, Türkiye Yüksek &Idott;htisas Hospital, Ankara, Turkey
| | - Ahmet Irdem
- Department of Cardiovascular Surgery, Türkiye Yüksek &Idott;htisas Hospital, Ankara, Turkey
| | - Erdem Cetin
- Department of Cardiovascular Surgery, Türkiye Yüksek &Idott;htisas Hospital, Ankara, Turkey
| | - Levent Altinay
- Department of Cardiovascular Surgery, Türkiye Yüksek &Idott;htisas Hospital, Ankara, Turkey
| | - Ufuk Tutun
- Department of Cardiovascular Surgery, Türkiye Yüksek &Idott;htisas Hospital, Ankara, Turkey
| | - Ferit Cicekcioglu
- Department of Cardiovascular Surgery, Türkiye Yüksek &Idott;htisas Hospital, Ankara, Turkey
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Shapira Y, Vaturi M, Sagie A. Obstructive left-sided prosthetic valve thrombosis. ACTA ACUST UNITED AC 2009; 11:160-8. [DOI: 10.1080/17482940903059143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Maribas P. Management of prosthetic heart valve obstruction: Speech for the surgery? Arch Cardiovasc Dis 2009; 102:255-7. [PMID: 19427602 DOI: 10.1016/j.acvd.2009.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Accepted: 03/12/2009] [Indexed: 11/29/2022]
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Management of prosthetic heart valve obstruction: Fibrinolysis versus surgery. Early results and long-term follow-up in a single-centre study of 263 cases. Arch Cardiovasc Dis 2009; 102:269-77. [DOI: 10.1016/j.acvd.2009.01.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Revised: 01/26/2009] [Accepted: 01/26/2009] [Indexed: 11/21/2022]
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Gallardo Lobo R, Sánchez PL, San Román JA, Fernández-Avilés F. Prosthetic mitral valve thrombosis treated with two consecutive courses of fibrinolysis. Rev Esp Cardiol 2009; 62:452-454. [PMID: 19401133 DOI: 10.1016/s1885-5857(09)71675-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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Gallardo Lobo R, Sánchez PL, San Román JA, Fernández-Avilés F. Trombosis protésica mitral tratada con dos fibrinolisis consecutivas. Rev Esp Cardiol (Engl Ed) 2009. [DOI: 10.1016/s0300-8932(09)70905-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kaya EB, Kocabas U, Aytemir K, Tokgozoglu L. Successful fibrinolytic treatment in an old patient with acute aortic prosthetic thrombosis. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2008; 9:581-3. [DOI: 10.1093/ejechocard/jen072] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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21
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Christiansen S, Fehske W, Autschbach R. Insufficiency of an Aortic Valve Prosthesis due to Tissue Ingrowth: A Case Report. Heart Surg Forum 2007; 10:E105-6. [PMID: 17597030 DOI: 10.1532/hsf98.20061097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Tissue ingrowth of a prosthetic heart valve usually leads to a stenosis. We report a rare case of a patient with a fixation of the prosthetic leaflet due to tissue ingrowth. This state caused a total prosthetic insufficiency. The therapy used to treat this prosthetic heart valve with tissue ingrowth is discussed in this report.
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Affiliation(s)
- Stefan Christiansen
- Department of Cardiothoracic Surgery, University of Aachen, Aachen, Germany.
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22
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Sakamoto Y, Hashimoto K, Okuyama H, Ishii S, Shingo T, Kagawa H. Prevalence of pannus formation after aortic valve replacement: clinical aspects and surgical management. J Artif Organs 2006; 9:199-202. [PMID: 16998706 DOI: 10.1007/s10047-006-0334-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2005] [Accepted: 04/03/2006] [Indexed: 11/28/2022]
Abstract
Pannus formation after aortic valve replacement is not common, but obstruction due to chronic pannus is one of the most serious complications of valve replacement. The causes of pannus formation are still unknown and effective preventive methods have not been fully elucidated. We reviewed our clinical experience of all patients who underwent reoperation for prosthetic aortic valve obstruction due to pannus formation between 1973 and 2004. We compared the initial 18-year period of surgery, when the Björk-Shiley tilting-disk valve was used, and the subsequent 13-year period of surgery, when the St. Jude Medical valve was used. Seven of a total of 390 patients (1.8%) required reoperation for prosthetic aortic valve obstruction due to pannus formation. All seven patients were women; four patients underwent resection of the pannus and three patients needed replacement of the valve. The frequency of pannus formation in the early group was 2.4% (6/253), whereas it was 0.73% (1/137) in the late group (P < 0.05). Pannus was localized at the minor orifice of the Björk-Shiley valve in the early group and turbulent transvalvular blood flow was considered to be one of the important factors triggering its growth. We also consider that small bileaflet valves have the possibility of promoting pannus formation and that the implantation of a larger prosthesis can contribute to reducing the occurrence of pannus.
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Affiliation(s)
- Yoshimasa Sakamoto
- Department of Cardiovascular Surgery, Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo 105-8461, Japan
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Cáceres-Lóriga FM, Pérez-López H, Santos-Gracia J, Morlans-Hernandez K. Prosthetic heart valve thrombosis: pathogenesis, diagnosis and management. Int J Cardiol 2005; 110:1-6. [PMID: 16038994 DOI: 10.1016/j.ijcard.2005.06.051] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2005] [Revised: 06/22/2005] [Accepted: 06/26/2005] [Indexed: 12/19/2022]
Abstract
Thrombosis of a prosthetic valve is one of the most severe complications of cardiac valve replacement. The incidence is 0.5% in the aortic and mitral positions and up to 20% in the tricuspid position. The presenting clinical picture ranges from the absence of symptoms to cardiogenic shock. The traditional treatment of this complication has been emergency surgery, but thrombolysis, which has been available for many years, is being considered as the first line of treatment more and more every day. The pathogenesis, diagnosis and treatment of thrombosis of prosthetic heart valves are reviewed here. Thrombolysis, which has an efficacy of over 80%, is emphasized in this review. Embolic complications associated with this therapeutic approach remain a great concern with rates of 3% to 10%, and some authors reporting rates up to 20%.
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24
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Kogon B, Kirshbom PH, Forbess JM, Kanter KR. Thrombolytic therapy for prosthetic valve thrombosis in children: two case reports and review of the literature. J Thorac Cardiovasc Surg 2004; 127:1519-22. [PMID: 15116020 DOI: 10.1016/j.jtcvs.2003.11.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Brian Kogon
- Emory University, Egleston Hospital, Children's Healthcare of Atlanta, Department of Pediatric Cardiothoracic Surgery, GA 30306, USA
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Abstract
Treatment of native valvular heart disease has resulted in an increasing number of patients with prosthetic valves. Although an improvement over the diseased native valve removed at surgery, prosthetic valves have suboptimal hemodynamics; mechanical valves require anticoagulation and tissue valves wear out over time. Serious complications of prosthetic valves occur at a rate of about 2% to 3% per patient-year. Complications include thromboembolism, prosthesis-patient mismatch, structural valve dysfunction, endocarditis, and hemolysis. Prosthetic valve endocarditis is a lethal disease with mortality rates of 50% to 80% even with appropriate therapy. Echocardiography now provides detailed information on valve function and hemodynamics, allowing early detection of complications. Many of these complications can be prevented by choosing the optimal valve at the time of surgery, rigorous control of anticoagulation and adherence to established anticoagulation guidelines, dental hygiene and endocarditis prophylaxis, and periodic echocardiographic monitoring by a cardiologist.
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Affiliation(s)
- Jeanne M Vesey
- Division of Cardiology, Box 356422, University of Washington, Seattle, WA 98195, USA
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26
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Tong AT, Roudaut R, Ozkan M, Sagie A, Shahid MSA, Pontes Júnior SC, Carreras F, Girard SE, Arnaout S, Stainback RF, Thadhani R, Zoghbi WA. Transesophageal echocardiography improves risk assessment of thrombolysis of prosthetic valve thrombosis: results of the international PRO-TEE registry. J Am Coll Cardiol 2004; 43:77-84. [PMID: 14715187 DOI: 10.1016/j.jacc.2003.08.028] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The goal of this study was to evaluate whether quantitation of thrombus burden with transesophageal echocardiography (TEE) can help risk-stratify patients undergoing thrombolysis of prosthetic valve thrombosis (PVT). BACKGROUND Thrombolytic therapy of PVT has an unpredictable risk of embolization and complications. METHODS An international registry of patients with suspected PVT undergoing two-dimensional/Doppler and TEE before thrombolysis was established. All TEE studies were reviewed and quantitated by a single observer blinded to all data. RESULTS From 1985 to 2001, 107 patients (71 females; age 24 to 86 years) from 14 centers (6 in the U.S.) were identified. The majority of cases involved the mitral valve (79 mitral, 13 aortic, and 15 tricuspid). Hemodynamic success rate was achieved in 85% and was similar across valves. Overall complications were observed in 17.8%, and death in 5.6%. Predictors of complications were: New York Heart Association (NYHA) functional class, presence of shock, sinus tachycardia, hypotension, previous history of stroke, thrombus extension beyond the valve ring, and thrombus area. Multivariate analysis demonstrated that two variables were independent predictors of complications: thrombus area by TEE (odds ratio [OR] 2.41 per 1 cm2 increment, 95% confidence interval [CI] 1.12 to 5.19) and prior history of stroke (OR 4.55, 95% CI 1.35 to 15.38). A thrombus area <0.8 cm2 identified patients at lower risk for complications from thrombolysis, irrespective of NYHA functional class. CONCLUSIONS In PVT, the thrombus size imaged with TEE is a significant independent predictor of outcome. Transesophageal echocardiography can identify low-risk groups for thrombolysis irrespective of symptom severity and is therefore recommended in the management of prosthetic valve thrombosis.
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Affiliation(s)
- Ann T Tong
- Baylor College of Medicine, Houston, Texas, USA
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27
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Arnaiz Arnaiz V, Cobo Belaustegui M, Ballesteros Sanz A, Ruisánchez Villar C, Gutiérrez Morlote J, San José Garagarza J. Fibrinólisis con TNK en un caso de trombosis de prótesis valvular mitral. Med Intensiva 2004. [DOI: 10.1016/s0210-5691(04)70085-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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28
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Shapira Y, Vaturi M, Hasdai D, Battler A, Sagie A. The safety and efficacy of repeated courses of tissue-type plasminogen activator in patients with stuck mitral valves who did not fully respond to the initial thrombolytic course. J Thromb Haemost 2003; 1:725-8. [PMID: 12871407 DOI: 10.1046/j.1538-7836.2003.00117.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In carefully selected patients with stuck mitral valves, thrombolytic therapy is becoming an established therapeutic modality. However, the management of patient with a suboptimal response to an initial thrombolytic course is unclear. The objective was to evaluate the efficacy and safety of re-administration of tissue-type plasminogen activator (rt-PA) in patients with stuck mitral valves in whom the first thrombolytic course has failed to restore normal prosthetic valve function. The study group included patients who received rt-PA and did achieve a full restoration of valve function after the initial course. Data were gathered on the safety and success rates of additional thrombolytic courses in the same hospitalization period, and their predictors. Twelve patients with stuck mitral valves experienced a total of 13 episodes in which a full resolution of leaflet abnormality was not achieved after the initial thrombolytic course. A repeated thrombolytic course was attempted in 10 patients (11 episodes). Six patients (60%) showed full success rate with repeated thrombolysis, one (10%) showed partial success, and three patients (30%) had no improvement following the second course. These last three were those with initial failure. Age, gender, valve model, worst functional class, time since valve implantation and International Normalized Ratio (INR) levels were similar in both groups. No major adverse events were noted. In this small group of patients with stuck mitral valves, re-administration of rt-PA after a partial response to an initial thrombolytic course was effective and safe. However, total failure of the first thrombolytic course predicted inefficiency of further courses.
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Affiliation(s)
- Y Shapira
- The Dan Sheingarten Echocardiography Unit and Valvular Clinic, Department of Cardiology, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel.
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29
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Roudaut R, Lafitte S, Roudaut MF, Courtault C, Perron JM, Jaïs C, Pillois X, Coste P, DeMaria A. Fibrinolysis of mechanical prosthetic valve thrombosis: a single-center study of 127 cases. J Am Coll Cardiol 2003; 41:653-8. [PMID: 12598078 DOI: 10.1016/s0735-1097(02)02872-3] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study was designed to analyze the results of fibrinolytic treatment (FT) in a large single-center group of patients with prosthetic heart valve thrombosis (PHVT). BACKGROUND Fibrinolytic treatment of PHVT represents an alternative to surgery, but is still controversial because of the risk of embolism. METHODS A total of 110 consecutive patients presenting with 127 instances of PHVT received FT between 1978 and 2001. The diagnosis of PHVT was established mainly by fluoroscopy and/or echocardiography. The first fibrinolytic agent used was streptokinase (SK) in 49 cases, urokinase (UK) in 41 cases, and recombinant tissue-type plasminogen activator (rtPA) in 37 cases. A second FT was consecutively infused in 38 patients (30%) and a third FT in 11 others. The efficacy of FT was assessed from hemodynamic parameters derived from echographic examinations as well as on clinical grounds. RESULTS Complete resolution of hemodynamic abnormalities was seen in 90/127 patients, partial resolution in 22/127 patients, and no change in 15/127 patients after one or more consecutive fibrinolytic regimens. When SK or rtPA were used as the first fibrinolytic agent, they appeared significantly superior to UK in terms of valve reopening. Fifteen patients died. Severe hemorrhagic complications were observed in six patients. Nineteen documented embolic events occurred during FT. Finally, PHVT recurred in 24 patients, 17 of whom were retreated with lytic agents. CONCLUSIONS These results indicate that FT is effective in most cases of PHVT, regardless of prosthesis or site involved. However, embolism, hemorrhage, and death were not uncommon after lytic therapy of left-sided PHVT, limiting its application to patients at high risk with alternative treatment.
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Affiliation(s)
- Raymond Roudaut
- I.F.R. 4 - F.R. 21 Coeur-Poumons-Vaisseaux-Thrombose, Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, 33604 Pessac, France.
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30
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Behrendt P, Schwartzkopff B, Perings S, Gerhardt A, Zotz RB, Strauer BE. Successful thrombolysis of st. Jude medical aortic prosthesis with tissue-type plasminogen activator in a pregnant woman: a case report. Cardiol Rev 2002; 10:349-53. [PMID: 12390690 DOI: 10.1097/00045415-200211000-00007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Mechanical valve thrombosis is a life-threatening event. Pregnancy is associated with a hypercoagulable state that further emphasizes the importance of adequate anticoagulation. This is associated with a therapeutic dilemma. Continued anticoagulation with warfarin throughout the first trimester can result in fetopathic effects, while replacement of warfarin by heparin between 6 and 12 weeks of gestation does not completely prevent the risk of valve thrombosis. There are a small number of reported cases of pregnant women with prosthetic heart valve thrombosis under low molecular weight heparin and consecutive lytic therapy. The authors report a 33-year-old pregnant woman with a St. Jude Medical aortic prosthesis, anticoagulated with a therapeutic dosage of low molecular weight heparin from 6 weeks of gestation, who developed prosthetic heart valve thrombosis at 17 weeks of gestation. A thrombolysis with recombinant tissue-type plasminogen activator (50 mg for 2 hours) was performed. Under thrombolysis, ST-segment elevation in leads II, III, aVF, V5, and V6 developed electrocardiographically with a maximal creatine kinase (CK) of 349 U/L (CK-MB isoenzyme of 48 U/L). Echocardiography revealed normal function of the St. Jude Medical aortic prosthesis 2 hours after thrombolysis and normal wall motions. Short-course thrombolytic therapy appears to be an effective alternative to surgical intervention for the treatment of thrombotic dysfunction of valve prostheses in pregnancy.
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Affiliation(s)
- P Behrendt
- Department of Medicine, Division of Cardiology, Angiology, and Pneumology, Heinrich-Heine-University, Germany.
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31
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López HP, Cáceres Lóriga FM, Hernàndez KM, Sánchez HF, González Jimenez N, Marrero Mirayaga MA, López Saura P, Sigarroa F, Mendoza Y, Rodríguez Alvarez J. Thrombolytic therapy with recombinant streptokinase for prosthetic valve thrombosis. J Card Surg 2002; 17:387-93. [PMID: 12630535 DOI: 10.1111/j.1540-8191.2001.tb01164.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Thrombosis is a serious complication of prosthetic heart valves, and management is often difficult. Thrombolytic therapy is a promising alternative to valve re-operation in the prosthetic valve thrombosis. METHODS Fifteen consecutive patients with prosthetic heart valve thrombosis (10 mitral, 3 aortic, 2 tricuspid) were treated with intravenous recombinant streptokinase: 250,000 UI given over 30 minutes followed by an infusion an 100,000 UI per hour, always with clinical monitoring and echocardiographic examinations repeated at 24, 48, and 72 hours after starting thrombolytic therapy. Doppler echocardiography was the primary method use for diagnosis and was also used to follow the response to therapy RESULTS Fibrinolytic treatment was successful in 14 (93.3%) patients. Total response was achieved in 13 (86.6%)patients and partial response in 1 (6.7%) patient; one patient died of ventricular fibrillation. No major hemorrhagic events were observed, peripheral embolism occurred in two cases, and one case of minor peripheral bleeding occurred in another. Some patients experienced fever and chills. CONCLUSIONS The present study demonstrates the feasibility, safety and efficacy of thrombolytic therapy, which may be considered as first-line therapy for prosthetic heart valve thrombosis.
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32
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Ohata T, Sakakibara T, Takano H, Ishizaka T. Acute thrombotic obstruction of mitral valve prosthesis: low protein C level. Asian Cardiovasc Thorac Ann 2002; 10:165-6. [PMID: 12079945 DOI: 10.1177/021849230201000218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 51-year-old female underwent redo mitral valve replacement with a pericardial bioprosthesis because of acute thrombotic obstruction of a mechanical valve, in spite of adequate anticoagulation with warfarin. Her protein C level was 24% of the normal value and protein S was reduced to 54% of normal.
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Affiliation(s)
- Toshihiro Ohata
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan.
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33
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Teshima H, Hayashida N, Nishimi M, Tayama E, Fukunaga S, Tomoeda H, Chihara S, Enomoto N, Kawara T, Aoyagi S. Thrombolytic therapy with tissue plasminogen activator for the treatment of nonstructural malfunction of bileaflet cardiac valve prostheses. Artif Organs 2002; 26:460-6. [PMID: 12000444 DOI: 10.1046/j.1525-1594.2002.06988.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study was conducted to determine the effect of thrombolytic therapy with tissue plasminogen activator (t-PA) for nonstructural malfunction of bileaflet cardiac valve prostheses. Twenty-seven patients with bileaflet prosthetic valve malfunction diagnosed by a combination of cineradiography and transthoracic echocardiography were treated with the administration of intravenous t-PA. The treatment resulted in complete success in 55.6% (15 of 27), partial success in 22.2% (6 of 27), and no change in 22.2% (6 of 27). In the complete success and partial success groups, the condition of the patients in 85.7% (18 of 21) of the cases improved within 24 h after the administration of t-PA. Six cases in whom thrombolytic therapy was instituted more than 1 month (ranged from 1 to 38 months, mean 14.7 months) after the diagnosis of prosthetic valve malfunction showed significantly less effectiveness of thrombolytic therapy with t-PA. Only one patient (3.7%) had a major complication (thromboembolism) after t-PA treatment. The results suggest that thrombolytic therapy with t-PA in patients with nonstructural malfunction of bileaflet cardiac valve prostheses is effective with low incidence of complication when the treatment is instituted early after the diagnosis.
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Affiliation(s)
- Hideki Teshima
- Department of Surgery, Kurume University School of Medicine, Asashi-machi, Kurume, Japan.
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34
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Licata A, Matthai WH. Evaluating the etiology of mechanical valve obstruction: use of clinical parameters, fluoroscopy, and echocardiography. Catheter Cardiovasc Interv 2002; 55:495-500. [PMID: 11948898 DOI: 10.1002/ccd.10096] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Prosthetic valve obstruction is a life-threatening complication most commonly caused by thrombus, pannus, or both. We report a St. Jude tricuspid valve obstruction, initially treated with thrombolytic therapy, found to be caused by pannus on pathologic examination. Clinical evaluation and diagnostic evaluation with fluoroscopy and echocardiography in distinguishing pannus from thrombus are reviewed.
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Affiliation(s)
- Anthony Licata
- Division of Cardiovascular Medicine, University of Pennsylvania Medical School, Philadelphia, Pennsylvania 19104, USA.
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35
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Azpitarte J, Sánchez-Ramos J, Urda T, Vivancos R, Oyonarte JM, Malpartida F. [Prosthetic valve thrombosis: which is the most appropriate initial therapy?]. Rev Esp Cardiol 2001; 54:1367-76. [PMID: 11754805 DOI: 10.1016/s0300-8932(01)76519-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND OBJECTIVES This study aims to investigate what is the best initial therapy for patients with obstructive prosthetic valve thrombosis. METHODS Data from 47 patients diagnosed with prosthetic valve thrombosis in two tertiary hospitals during an 8-years period were analyzed. RESULTS The involved prostheses were in mitral position in 34 cases (2 biological valves), in aortic position in 12, and in double mitral and aortic position in one. The thrombosis was not obstructive in 12 patients. In the remaining 35 patients, the prosthetic obstruction was treated by heparin (n = 2), thrombolysis (n = 19), or direct surgery (n = 14). There was no mortality in the thrombolytic group, although 6 patients needed surgery before discharge because of an abnormal prosthetic residual gradient (n = 5) or a persisting abnormal disc valve motion (n = 1). Five out of 14 patients of direct surgery died, 2 before the planned operation could be performed. Thus, mortality rate, in an intention to treat analysis, was very favourable to thrombolytic therapy (p = 0.008); and this, despite the higher index of clinical severity (on a scale from 0 to 4) was superior in this group of thrombolyzed patients: 3.3 0.6 vs. 2.1 0.9 in those who underwent surgery; p < 0.0001. CONCLUSIONS In terms of mortality rate, thrombolysis is a better alternative than direct surgery to fight against obstructive prosthetic valve thrombosis. Even if the result is suboptimal, it allows the performance of surgery in better clinical conditions and, thus, with minor risk.
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Affiliation(s)
- J Azpitarte
- Servicios de Cardiología de los Hospitales Virgen de las Nieves de Granada y aCarlos de Haya Málaga.
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36
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Martín Herrero F, Sánchez Fernández PL, Piedra Bustamante I, Moríñigo Muñoz JL, Nieto Ballestero F, Martín Luengo C. [Mitral prosthesis thrombosis treated by fibrinolysis with accelerated administration of r-TPA]. Rev Esp Cardiol 2001; 54:1448-51. [PMID: 11754792 DOI: 10.1016/s0300-8932(01)76529-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We report the case of a 53-year-old patient with a mitral prosthesis hospitalized for heart failure. Diagnosis of mitral prosthetic thrombosis, led to a therapeutic disjunction between thrombolysis and surgery. Because of the high risk of surgical intervention, the patient was treated with r-TPA (accelerated infusion), showing immediate, successful response.
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37
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Gulati M, Furlong K, DeCara J, Spencer KT, Lang RM. Thrombolytic therapy of a left-sided prosthetic valve thrombosis without hemodynamic obstruction: a case report. J Am Soc Echocardiogr 2001; 14:1230-4. [PMID: 11734793 DOI: 10.1067/mje.2001.114396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We report a case of a 38-year-old woman with a prosthetic mitral valve who presented with multiple embolic events. Transesophageal echocardiography was used to diagnose nonobstructive thrombi on the prosthetic valve. She underwent successful thrombolytic therapy. The patient was discovered to be in a hypercoagulable state, which probably was caused by the concomitant use of phenytoin. We review the literature for diagnosis and treatment of nonobstructive prosthetic valve thrombosis.
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Affiliation(s)
- M Gulati
- University of Chicago, Division of Cardiology, Department of Medicine, Illinois 60637, USA
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38
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Tsiouris N, Ahmad M. Prosthetic valve thrombosis and thrombolysis: a case report and review of the literature. Am J Med Sci 2001; 322:229-32. [PMID: 11678521 DOI: 10.1097/00000441-200110000-00014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Prosthetic valve thrombosis is a rare but serious complication of implanted mechanical valves. Thrombolysis has emerged as an alternative to surgical therapy in the management of these patients. The indications for such therapy and appropriate patient selection are evolving. Our report describes management of a patient we encountered with this complication and reviews the current status of thrombolysis in such patients.
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Affiliation(s)
- N Tsiouris
- Division of Cardiology, The University of Texas Medical Branch, Galveston 77555-0766, USA
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39
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Lin SS, Tiong IY, Asher CR, Murphy MT, Thomas JD, Griffin BP. Prediction of thrombus-related mechanical prosthetic valve dysfunction using transesophageal echocardiography. Am J Cardiol 2000; 86:1097-101. [PMID: 11074206 DOI: 10.1016/s0002-9149(00)01166-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Identification of thrombus-related mechanical prosthetic valve dysfunction (MPVD) has important therapeutic implications. We sought to develop an algorithm, combining clinical and echocardiographic parameters, for prediction of thrombus-related MPVD in a series of 53 patients (24 men, age 52 +/- 16 years) who had intraoperative diagnosis of thrombus or pannus from 1992 to 1997. Clinical and echocardiographic parameters were analyzed to identify predictors of thrombus and pannus. Prevalence of thrombus and diagnostic yields relative to the number of predictors were determined. There were 22 patients with thrombus, 19 patients with pannus, and 12 patients with both. Forty-two of 53 masses were visualized using transesophageal echocardiography (TEE), including 29 of 34 thrombi or both thrombi and panni and 13 of 19 isolated panni. Predictors of thrombus or mixed presentation include mobile mass (p = 0.009), attachment to occluder (p = 0.02), elevated gradients (p = 0.04), and an international normalized ratio of < or = 2.5 (p = 0.03). All 34 patients with thrombus or mixed presentation had > or = 1 predictor. The prevalence of thrombus in the presence of < or = 1, 2, and > or = 3 predictors is 14%, 69%, and 91%, respectively. Thus, TEE is sensitive in the identification of abnormal mass in the setting of MPVD. An algorithm based on clinical and transesophageal echocardiographic predictors may be useful to estimate the likelihood of thrombus in the setting of MPVD. In the presence of > or = 3 predictors, the probability of thrombus is high.
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Affiliation(s)
- S S Lin
- Department of Cardiology, The Cleveland Clinic Foundation, Ohio 44195, USA
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40
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Shapira Y, Herz I, Vaturi M, Porter A, Adler Y, Birnbaum Y, Strasberg B, Sclarovsky S, Sagie A. Thrombolysis is an effective and safe therapy in stuck bileaflet mitral valves in the absence of high-risk thrombi. J Am Coll Cardiol 2000; 35:1874-80. [PMID: 10841238 DOI: 10.1016/s0735-1097(00)00640-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We sought to evaluate the effectiveness and safety of thrombolytic therapy in stuck mitral bileaflet heart valves in the absence of high-risk thrombi. BACKGROUND Current recommendations for the thrombolytic treatment of stuck prosthetic mitral valves are partially based on older valve models and inclusion of patients in whom high-risk thrombi were either ignored or not sought for. The feasibility and safety of thrombolysis in bileaflet models may be affected by the predilection of thrombi to catch the leaflet hinge. METHODS We studied 12 consecutive patients (men/women = 5/7, age 58.8 +/- 14.9 years) who experienced one or more episodes of stuck bileaflet mitral valve over a 33-month period and received thrombolytic therapy with streptokinase, urokinase or tissue-type plasminogen activator. Transesophageal echocardiography was performed in all patients. Patients with mobile or large (>5 mm) thrombi were excluded. Functional class at initial episode was I-II in 4 patients (33.3%) and III-IV in 8 patients (66.6%). RESULTS Patients receiving thrombolytic therapy achieved an overall 83.3% freedom from a repeat operation or major complications (95% confidence interval 51.6-97.9%). Minor bleeding occurred in three patients (25%) and allergic reaction in one (8.3%). Transient vague neurologic complaints, without subjective findings, occurred in four patients (33.3%). Three patients had one or more relapses within 5.2 +/- 3.1 months from the previous episode, and readministration of thrombolytics was successful. CONCLUSIONS In clinically stable patients with stuck bileaflet mitral valves and no high-risk thrombi, thrombolysis is highly successful and safe, both in the primary episode and in recurrence. The best thrombolytic regimen is yet to be established.
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Affiliation(s)
- Y Shapira
- Dan Sheingarten Echocardiography Unit, Rabin Medical Center, Beilinson Campus, Petah-Tikva, Israel
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41
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Ozkan M, Kaymaz C, Kirma C, Sönmez K, Ozdemir N, Balkanay M, Yakut C, Deligönül U. Intravenous thrombolytic treatment of mechanical prosthetic valve thrombosis: a study using serial transesophageal echocardiography. J Am Coll Cardiol 2000; 35:1881-9. [PMID: 10841239 DOI: 10.1016/s0735-1097(00)00654-9] [Citation(s) in RCA: 118] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- M Ozkan
- Kosuyolu Heart and Research Hospital, Istanbul, Turkey
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42
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Montorsi P, Cavoretto D, Ballerini G. Thrombosis of mechanical heart valve prostheses: revisiting the role of fluoroscopy. Br J Radiol 2000; 73:76-9. [PMID: 10721325 DOI: 10.1259/bjr.73.865.10721325] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Prosthetic valve thrombosis is a rare but potentially fatal complication of heart valve replacement. Symptoms may be misleading, yet the condition may rapidly lead to death. A prompt diagnosis is therefore crucial. Ultrasound is the most often used technique for evaluating prosthesis dysfunction. We describe two cases of prosthesis thrombosis with negative Doppler results but with distinctly abnormal leaflet motion at fluoroscopy. A correct diagnosis would have been missed if the Doppler evaluation alone was relied on. Fluoroscopy should always form part of the diagnostic work-up in patients with artificial heart valves.
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Affiliation(s)
- P Montorsi
- Catheterization Laboratory, University of Milan, Italy
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Rittoo D, Buckley H, Cotter L. Recurrent prosthetic valve thrombosis: importance of prolonged Doppler echocardiography examination for diagnosis. J Am Soc Echocardiogr 1999; 12:686-8. [PMID: 10441227 DOI: 10.1053/je.1999.v12.a99248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In a 9-month period a 52-year-old woman was admitted on 3 occasions with thrombotic obstruction of a Medtronic Hall aortic valve prosthesis. On the first occasion the diagnosis was clinically obvious; on the second occasion prosthetic valve malfunction was detected fortuitously on Doppler echocardiography; on the third occasion the diagnosis was made after prolonged Doppler echocardiographic examination. The patient was treated with thrombolysis, surgical thrombectomy, and aortic valve re-replacement on the 3 occasions, respectively.
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Affiliation(s)
- D Rittoo
- Department of Cardiology, Manchester Royal Infirmary, M13 9SB, UK.
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44
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Affiliation(s)
- T E David
- Division of Cardiovascular Surgery, Toronto General Hospital, University of Toronto, Ontario, Canada
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45
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Katircioğlu SF, Ulus AT, Yamak B, Ozsöyler I, Birincioğlu L, Taşdemir O. Acute mechanical valve thrombosis of the St. Jude medical prosthesis. J Card Surg 1999; 14:164-8. [PMID: 10789701 DOI: 10.1111/j.1540-8191.1999.tb00971.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
From 1986 to 1996, 2585 patients underwent valve replacement with the St. Jude medical prosthesis. Sixty experienced mechanical valve thrombosis. Seventeen of 60 patients (28.3%) had isolated aortic valve replacements, 33 had isolated mitral valve replacements (55%), and 10 had double valve replacements (16.7%) (aortic and mitral valve replacement). All patients who underwent reoperation for mechanical valve thrombosis were functional Class III or IV. Against medical advice, systemic anticoagulation with warfarin sodium had been discontinued or used only intermittently. Thus, anticoagulant activity was not adequate. The diagnosis of thrombosis was made by clinical examination, laboratory findings, and echocardiography and cineradiography. Of the 60 patients, 9 patients died early after surgery or before discharge. Most of the deaths were attributed to low cardiac output. The overall hospital mortality was 15%. The overall 10-year actuarial survival rate was 82.8+/-1.6%. In our study, reoperation for thrombosed mechanical prosthesis was not an independent parameter determining mortality. Age was the only statistically important hospital mortality predictor. Of this group, 90% suffered mechanical valve obstruction within the first 5 years after operation. These results suggest that valve re-replacement appears to be a suitable surgical treatment for thrombosis of mechanical prosthetic valves, especially in the young. In these patients subsequent anticoagulation management is necessary.
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Affiliation(s)
- S F Katircioğlu
- Department of Cardiovascular Surgery, Türkiye Yüksek Ihtisas Hospital, Ankara, Turkey
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46
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Breuer M, Schütz A, Gansera B, Eichinger W, Weingartner J, Kemkes B. Intraoperative local fibrinolysis as emergency therapy after early coronary artery bypass thrombosis. Eur J Cardiothorac Surg 1999; 15:266-70. [PMID: 10333021 DOI: 10.1016/s1010-7940(99)00010-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVE Acute graft occlusion early postoperatively after coronary artery bypass grafting (CABG) is a rare but dramatic complication, frequently making resuscitation necessary. Emergency reoperation with reanastomosing of the concerning grafts is the normal procedure to restrict the otherwise unavoidable myocardial damage. Mortality in these cases is up to 50%. Due to this unsatisfying situation, we perform since 1995 in such cases an adjuvant intraoperative intracoronary installed fibrinolysis with recombinant tissue type plasminogen activator (rt-PA; alteplase). METHODS Between 1/1994 and 8/1998, 4231 patients underwent CABG. In 18 of these patients, emergency reoperation within the first 12 h after CABG due to clinical signs of acute myocardial infarction was necessary. In nine of the patients (group II) additionally intraoperative rt-PA lysis of the involved vessel/s has been performed. When the peripheral anastomosis was reopened and the thrombotic material was removed, we inserted for this a left atrial-catheter (LA-catheter) of 1.2 mm in diameter, into the coronary artery. Then we administered within 3-5 min, up to 100 mg rt-PA (t1/2: 5-9 min.) locally into the vessel. All patients were treated postoperatively with acetylsalicyl acid (ASA) and heparine. RESULTS In group I (n = 9; seven males, two females) without thrombolytic therapy, 78% of the patients (n = 7) could not have been prevented from large myocardial infarction despite emergency reoperation. Three of these patients died during or early after reintervention. In group II with fibrinolytic therapy (n = 9) three of the patients developed Q-wave myocardial infarction following reoperation. None of the patients died. Creatinkinase maximum were in group I significantly higher than in group II (group I: CK = 1254 units/I, CK-MB = 197 units/l; group II: CK = 502 units/l, CK-MB = 61 units/l; P < 0.01). Postoperative bleeding was considerable elevated in both groups. In group I, 832 ml/24 h (375-1420 ml), in group II 1164 ml/24 h (520-1560 ml). Lysis-associated complications were not observed. CONCLUSIONS Reoperation of patients with acute thrombotic bypass occlusion after CABG is characterized by a high mortality and morbidity. If additionally fibrinolysis is performed, a sufficient myocardial perfusion seems to be restored. A short half-life in combination with the presented non-systemic application technique of rt-PA seem to prevent unpredictable bleeding. Rt-PA lysis apparently contributes very effectively to the restoration of the macro- and microcirculation within the infarct-related area. Thrombolytic therapy during cardiac surgery with rt-PA is feasible, its application easy and harmful complications are not seen.
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Affiliation(s)
- M Breuer
- Department of Cardiovascular Surgery, Klinikum Bogenhausen, Munich, Germany
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Mylonakis E, Kon D, Moulton A, Elion J, Indeglia R, Koutkia P, Katz A. Thrombosis of mitral valve prosthesis presenting as abdominal pain. Heart Lung 1999; 28:110-3. [PMID: 10076110 DOI: 10.1053/hl.1999.v28.a96419] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A 67-year-old woman presented with abdominal pain, anemia, and leukocytosis. Five years previously, the patient had undergone mitral valve replacement with a St. Jude bileaflet mechanical prosthesis. After her admission, echocardiography confirmed an immobile leaflet of the prosthetic valve. At urgent surgery, thrombosis and pannus, obstructing the disc, were found, and the mechanical valve was replaced with a bioprosthesis. The incidence of mitral valve thrombosis is low, ranging from 0.1% to 5.7% per patient per year. Patients who receive inadequate anticoagulation, particularly with valve prostheses in the mitral position, have an increased risk for thrombus or pannus formation. Presentation varies, from symptoms of congestive heart failure or systemic embolization, to fever or no symptoms. New or worsening symptoms in a patient with a prosthetic heart valve should raise concerns about prosthetic dysfunction. Aggressive investigation and, if indicated, urgent or emergency surgery for treatment can be lifesaving.
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Affiliation(s)
- E Mylonakis
- Miriam Hospital, Brown University Medical School, Providence, RI 02906, USA
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48
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Abstract
Mechanical prosthetic valve thrombosis is a life-threatening complication necessitating immediate intervention. The presenting signs and symptoms of this illness are somewhat variable, but physical examination and transesophageal echocardiography enable rapid diagnosis. To avoid catastrophic complications, valve replacement or debridement, or thrombolysis in the correct setting, must be performed without delay. It is not entirely clear which therapy is superior. For any given patient, the risks of thrombolytic therapy, including bleeding, systemic embolism, and failure to restore valvular function, must be weighed against the risks of surgical intervention. Once the decision is made to operate, the choice of valve replacement versus debridement is one best made intraoperatively, upon visual inspection of the valve apparatus. Despite aggressive therapy, morbidity and mortality from prosthetic valve thrombosis and its treatment are not trivial. Fortunately, with current prosthetic devices and aggressive prophylactic anticoagulation, the incidence of prosthetic valve thrombosis remains low. Antiplatelet therapy may offer additional benefit to patients being prophylaxed with warfarin. This report details the case of a woman with aortic and mitral prosthetic valves who presented with heart failure and evidence of severe aortic prosthetic dysfunction after a period of suboptimal anticoagulation. She successfully underwent debridement of the mitral prosthesis and replacement of the aortic valve. The relevant literature is reviewed.
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Manteiga R, Carlos Souto J, Altès A, Mateo J, Arís A, Dominguez JM, Borrás X, Carreras F, Fontcuberta J. Short-course thrombolysis as the first line of therapy for cardiac valve thrombosis. J Thorac Cardiovasc Surg 1998; 115:780-4. [PMID: 9576210 DOI: 10.1016/s0022-5223(98)70355-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To retrospectively evaluate the clinical and echocardiographic criteria of thrombolytic therapy for mechanical heart valve thrombosis. METHODS Nineteen consecutive patients with 22 instances of prosthetic heart valve thrombosis (14 mitral, 2 aortic, 3 tricuspid, and 3 pulmonary) were treated with short-course thrombolytic therapy as first option of treatment in absence of contraindications. The thrombolytic therapy protocol consisted of streptokinase (1,500,000 IU in 90 minutes) (n = 18) in one (n = 7) or two (n = 11) cycles or recombinant tissue-type plasminogen activator (100 mg in 90 minutes) (n = 4). RESULTS Overall success was seen in 82%, immediate complete success in 59%, and partial success in 23%. Six patients without total response to thrombolytic therapy underwent surgery, and pannus was observed in 83%. Six patients showed complications: allergy, stroke, transient ischemic attack, coronary embolism, minor bleeding, and one death. At diagnosis, 10 patients evidenced atrial thrombus by transesophageal echocardiography, 3 of whom experienced peripheral embolism during thrombolysis. Four episodes of rethrombosis were observed (16%). The survivorship was 84% with a mean follow-up of 42.6 months. CONCLUSIONS A short-course of thrombolytic therapy may be considered first-line therapy for prosthetic heart valve thrombosis. The risk of peripheral embolism may be evaluated for the presence of atrial thrombus by transesophageal echocardiography at diagnosis.
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Affiliation(s)
- R Manteiga
- Thrombosis and Hemostasis Unit, Hospital de la Sta Creu i St Pau, Barcelona, Spain
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50
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Munclinger MJ, Patel JJ, Mitha AS. Thrombolysis of thrombosed St. Jude Medical prosthetic valves: rethrombosis--a sign of tissue ingrowth. J Thorac Cardiovasc Surg 1998; 115:248-9. [PMID: 9451074 DOI: 10.1016/s0022-5223(98)70468-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- M J Munclinger
- Department of Cardiology, University of Natal/Wentworth Hospital, Durban, KwaZulu/Natal, South Africa
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