Prosthetic valve thrombosis (PVT) is one of the most serious long-term complications after heart valve replacement, and optimal treatment remains unclear. The investigators report clinical characteristics and outcome of all consecutive patients with PVT treated with urgent surgery or thrombolysis with recombinant tissue plasminogen activator at a single center from January 1988 to December 2008. Thirty-one patients (mean age 59 years, range 20 to 75, 19% men) were diagnosed with PVT a median of 11 years after valve replacement (range 4 months to 32 years). Affected valve positions were mitral in 17 (55%), aortic in 8 (26%), and tricuspid in 6 (19%), and all but 1 were mechanical valves. Eighteen patients underwent urgent surgery, with 2 deaths in the immediate perioperative phase and 2 recurrences (11%) of PVT over a median follow-up period of 76 months. Of 13 patients treated with thrombolysis, there was immediate clinical improvement after a single administration of recombinant tissue plasminogen activator in 12 (92%), of whom 8 (61%) showed complete response with normalization of echocardiographic findings. The only nonresponder was subsequently referred for urgent surgery. Over a median follow-up period of 18 months, recurrence of PVT was seen in 4 patients (31%), with 1 fatal event in a patient refusing further anticoagulation treatment 1 week after successful thrombolysis. Other complications in the recombinant tissue plasminogen activator group included 1 stroke, 1 transient ischemic attack, 1 hemorrhagic complication requiring surgery, and 2 peripheral embolic events with spontaneous resolution. In conclusion, thrombolysis is an attractive first-line therapy for patients with PVT, with clinical outcomes comparing favorably with the standard surgical approach.
We conducted a single-center retrospective study of all cases of obstructive prosthetic valve thrombosis (PVT) over the past 20 years. All patients underwent urgent surgery or received thrombolysis with recombinant tissue plasminogen activator (rt-PA) as initial treatment. Clinical characteristics and outcomes of patients are described.
Methods
All patients with obstructive PVT presenting to a single tertiary referral medical center were identified from the databases of the echocardiography laboratory, the cardiac intensive care unit, the emergency department, and the cardiac surgery department. The database search was approved by the local ethics committee.
A diagnosis of PVT was based on transthoracic and/or transesophageal echocardiographic findings. PVT was considered obstructive if prosthetic valve dysfunction was observed in the presence of thrombus. In 11 patients, additional cine fluoroscopy was performed.
The choice between surgery or thrombolysis was left to the treating physician’s preference. For patients who underwent thrombolysis, the applied fibrinolysis regimen included rt-PA (Boeringher Ingelheim, Ingelheim, Germany) in a loading dose of 10 mg, followed by 90 mg for 2 hours with concomitant heparin treatment. Efficacy of fibrinolytic therapy was evaluated from clinical data and echocardiographic and cine fluoroscopic findings. Success was defined as (1) complete: hemodynamic normalization confirmed by cine fluoroscopy (normal mobility) or transthoracic or transesophageal echocardiographic data (normalization of transprosthetic gradient and valve area, normal mobility of leaflet); (2) partial: significant clinical improvement without complete recovery of disc or leaflet motion on fluoroscopy and/or transesophageal echocardiography; or (3) failure: no clinical improvement.
Continuous variables are presented as medians and interquartile ranges or as mean ± SD as appropriate. Categorical variables are presented as observed frequencies and percentages. SPSS for Windows version 16.0 (SPSS, Inc., Chicago, Illinois) was used for statistical analysis.
Results
From January 1988 to December 2008, we identified 31 patients with PVT (mean age 59 years, range 20 to 75, 19% men). All but one had mechanical PVT (97%), with the remainder carrying a bioprosthesis. Valve types and positions are listed in Table 1 , as well as anticoagulation status. In our series, 15 of the 31 patients (48%) had documented inadequate international normalized ratios in the weeks before the event or at presentation. In 9 patients (29%), a temporary cessation of anticoagulation treatment within 2 months preceded the event. The time interval between valve replacement and thrombosis ranged from 3 months to 32 years (median 11). Clinical details are listed in Table 1 . Dyspnea was the presenting symptom in most patients (90%), with 13 patients (42%) in New York Heart Association (NYHA) functional class IV on presentation. Ten patients (33%) had hemodynamic compromise at the time of admission. Systemic embolic episodes were observed in 4 patients (13%), of whom 2 presented with chest pain, electrocardiographic changes, and elevated cardiac enzymes, mimicking acute coronary syndromes. Clinical examination revealed diminished heart sounds in 10 patients (32%). Twenty-one patients (68%) had histories of atrial fibrillation. In 19 patients (61%), symptoms started >1 week before the diagnosis of PVT.
| Patient Number | Age (years) | Valve Type | Valve Age (years) | History of AF | Suboptimal INR | OAC | NYHA Class | Initial Treatment | Perioperative Findings | Resolution | Complications | Recurrence (years) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Mitral (n = 17) | ||||||||||||
| 3 | 45 | M | 8 | Y | Y | N | III | Sur | T + P | CS | N | N |
| 19 | 46 | M | 11 | N | N | N | IV | Sur | T | CS | N | Y (3) |
| 16 | 49 | M | 3 | N | Y | N | II | Sur | T | CS | N | N |
| 1 | 51 | M | 11 | Y | N | N | IV | Sur | T + P | CS | N | N |
| 4 | 52 | M | 0.4 | N | N | N | IV | Sur | T | CS | N | Y (0.5) |
| 25 | 53 | M | 6 | N | Y | Y | IV | Lys | PS | Embolism | N | |
| 31 | 55 | M | 9 | N | N | Y | II | Sur | T | CS | Pacemaker | N |
| 23 | 56 | M | 6 | Y | Y | N | III | Lys | PS | N | N | |
| 18 | 58 | M | 7 | Y | Y | N | III | Lys | CS | N | Y (0.05) | |
| 2 | 63 | M | 16 | Y | N | Y | IV | Sur | T + P | CS | N | N |
| 13 | 63 | M | 7 | Y | Y | Y | III | Sur | T | CS | N | N |
| 14 | 64 | M | 14 | N | N | N | III | Lys | CS | N | Y (1) | |
| 24 | 68 | M | 10 | Y | Y | Y | III | Lys | CS | N | Y (0.1) | |
| 17 | 70 | M | 2 | N | N | N | IV | Lys | PS | N | Y (2.5) | |
| 22 | 70 | M | 27 | Y | Y | N | IV | Sur | T + P | CS | Sepsis, ICU >4 weeks | N |
| 10 | 71 | M | 22 | Y | N | N | IV | Lys | CS | Stroke, bleed | N | |
| 7 | 75 | B | 0.3 | Y | N | Y | IV | Lys | T | F | Embolism, Sur | N |
| Aortic (n = 8) | ||||||||||||
| 12 | 53 | M | 21 | Y | N | N | IV | Sur | T + P | CS | N | N |
| 30 | 54 | M | 13 | N | Y | Y | I | Lys | CS | TIA | N | |
| 5 | 57 | M | 7 | Y | N | N | IV | Sur | T | CS | N | N |
| 9 | 63 | M | 20 | Y | Y | N | III | Sur | T + P | CS | Revision VSD | N |
| 27 | 70 | M | 32 | Y | N | Y | II | Lys | PS | N | N | |
| 21 | 73 | M | 11 | Y | N | N | IV | Sur | T | F | Death | |
| 6 | 74 | M | 20 | Y | Y | N | IV | Sur | T + P | F | Death | |
| 11 | 74 | M | 2 | Y | Y | N | III | Sur | T | CS | Sternitis, ICU >4 weeks | N |
| Tricuspid (n = 6) | ||||||||||||
| 15 | 20 | M | 6 | N | N | N | II | Sur | T + P | CS | N | N |
| 28 | 46 | M | 3 | Y | Y | Y | III | Lys | CS | N | N | |
| 26 | 47 | M | 21 | N | Y | N | II | Lys | CS | N | N | |
| 8 | 54 | M | 0.5 | Y | N | N | III | Sur | T | CS | N | N |
| 20 | 59 | M | 28 | Y | N | N | II | Sur | T + P | CS | N | N |
| 29 | 61 | M | 9 | Y | Y | N | II | Lys | CS | N | N |
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