Ann Thorac Surg 1997;64:535-536
© 1997 The Society of Thoracic Surgeons
Case Reports
Thrombus Formation on a Calcific and Severely Stenotic Bicuspid Aortic Valve
Song Wan, MD, PhD,
Jean-Marie DeSmet, MD,
Jean-Louis Vincent, MD, PhD,
Jean-Louis LeClerc, MD
Departments of Cardiac Surgery and Intensive Care, University Hospital Erasme, Free University of Brussels, Brussels, Belgium
Accepted for publication March 18, 1997.
 |
Abstract
|
|---|
We report on a case of thrombus formation on a native bicuspid aortic valve, which was found during an elective operation for aortic valve replacement. Although no apparent predisposing cause of thrombosis could be ascertained, severe calcific stenosis of the bicuspid valve and cardiac catheterization may have played a role. The patient is in excellent condition 9 months after the operation.
|
Introduction
|
|---|
There are some case reports of spontaneous aortic thrombosis in the neonate [1] or in the adult [2], as well as thrombosis of aortic porcine bioprostheses [3, 4]. These rare events are often of uncertain origin and are usually fatal [1–3]. We observed during operation a case of thrombus formation on a native bicuspid aortic valve.
A 70-year-old man weighing 60 kg, with no history of smoking or chronic disease such as hypertension and diabetes, was admitted for aortic valve replacement. Six months before, the patient began having increasing dyspnea and effort angina. Two months before, a cardiac catheterization demonstrated severe aortic stenosis with a peak systolic gradient of 94 mm Hg. Cardiac output was 5.1 L/min. Right and left coronary cineangiograms were normal. Left ventricular angiography and aortography were not performed. Echocardiography showed an effective orifice area of 0.5 cm2 and severe calcification of the aortic valve. The left ventricle was hypertrophied (15 mm), with a calculated ejection fraction of 0.48. On admission, electrocardiography showed a sinus rhythm of 95 beats/min. Blood pressure was 114/66 mm Hg. Platelet count was 2.53 x 105/µL. Activated partial thromboplastin time was 25.6 seconds (normal, 20 to 35 seconds). Thrombin time was 15.6 seconds (normal, 15 to 20 seconds). The result of the ethanogelation test was negative. However, prothrombin time was 50% and 73% of control 24 hours and 14 hours before operation, respectively. Immediately before the operation, activated clotting time was 70 seconds.
After median sternotomy and initiation of cardiopulmonary bypass, aortotomy revealed an unsuspected, organized thrombus, which was firmly adherent to the aortic surface of the aortic valve (Fig 1
). The size of the thrombus was about 2.3 x 2 cm. After the thrombus was removed, a severely calcified, stenotic bicuspid aortic valve was excised (Fig 2) and replaced with a 23-mm Carpentier-Edwards bioprosthesis (Perimount; Baxter Healthcare Corp, Edwards Division, Santa Ana, CA). The patient was weaned uneventfully from cardiopulmonary bypass. Cardiac output was 4.9 L/min 20 minutes after discontinuation of cardiopulmonary bypass. The postoperative course of this patient was uncomplicated.
View larger version (103K):
[in this window]
[in a new window]
|
Fig 1. . Aortotomy revealed an organized thrombus firmly adherent to the aortic surface of the aortic valve.
|
|
View larger version (98K):
[in this window]
[in a new window]
|
Fig 2. . The thrombus and a severely calcified stenotic bicuspid aortic valve removed during the operation (the ruler is marked in centimeters).
|
|
Postoperative blood tests, including levels of antithrombin III, fibrinogen, protein C, protein S, and plasminogen, all had normal results. Microscopic examination showed no microorganism in the thrombus, which otherwise contained some neutrophils and fibrin material. The patient was discharged on the 9th postoperative day receiving only aspirin therapy. He was seen in excellent condition 9 months after the operation.
|
Comment
|
|---|
Spontaneous aortic thrombosis is a rare but usually catastrophic event. In our patient, this unusual occurrence in a severely calcific and stenotic native bicuspid aortic valve was found incidentally and was surgically treated. As in other cases, no apparent predisposing cause of thrombosis could be ascertained in this patient. Severe calcific stenosis of the bicuspid valve may have played a role. The thrombus formation may also have been initiated at the time of cardiac catheterization.
Bicuspid aortic valve is a congenital anatomic defect that represents one of the most common causes of aortic valvular dysfunction. It has been shown that about one third of all surgically excised aortic valves between 1965 and 1990 at the Mayo Clinic were bicuspid [5]. Interestingly, calcific stenosis accounted for 81% of those bicuspid aortic valves [5]. It is likely that calcific stenosis of the bicuspid aortic valve may have changed the fluidity of blood, which, in this particular patient, may have contributed to the formation of thrombus. On the other hand, it was suggested that aortic thrombosis in neonates may be related to umbilical artery catheterization [1]. Because cardiac catheterization was performed 2 months before the operation in this patient, a potential role of the procedure cannot be excluded.
It has been found that familial antithrombin III deficiency may result in thrombosis of a porcine aortic valve [4]. To explore the possibility of this underlying coagulation disorder is very important because such a patient should be maintained on warfarin therapy to avoid fatal complications. In the case presented here, however, this was not the cause of thrombosis.
|
Acknowledgments
|
|---|
We thank Prof Paul Capel for the postoperative laboratory studies.
|
Footnotes
|
|---|
Address reprint requests to Dr DeSmet, Department of Cardiac Surgery, University Hospital Erasme, Free University of Brussels, Route de Lennik 808, B-1070, Brussels, Belgium.
|
References
|
|---|
- Hamilton RM, Penkoske PA, Byrne P, Duncan NF. Spontaneous aortic thrombosis in a neonate presenting as coarctation. Ann Thorac Surg 1988;45:564–5.[Abstract/Free Full Text]
- Mestres CA, Campistol JM, Margarit LC, Almirall J, Condom E, Mulet J. Acute thrombosis of the thoracic aorta diagnosed during life: a rare entity [Letter]. J Thorac Cardiovasc Surg 1989;98:1149.[Medline]
- Baciewicz PA, del Rio C, Goncalves MA, Lattouf OM, Guyton RA, Morris DC. Catastrophic thrombosis of porcine aortic bioprostheses. Ann Thorac Surg 1990;50:817–9.[Abstract/Free Full Text]
- Gonzalez-Lavin L. Thrombosis of an aortic porcine xenobioprosthesis associated with familial antithrombin III deficiency. J Thorac Cardiovasc Surg 1984;88:631–3.[Abstract]
- Dare AJ, Veinot JP, Edwards WD, Tazelaar HD, Schaff HV. New observations on the etiology of aortic valve disease: a surgical pathologic study of 236 cases from 1990. Hum Pathol 1993;24:1330–8.[Medline]
This article has been cited by other articles:
|
|
|
|
 
R. J. Mendez, T. F. Cianciulli, C. E. Parisi, H. A. Prezioso, and L. A. Vidal
Recurrent systemic embolism caused by thrombosis in a stenotic bicuspid aortic valve
Eur Heart J Cardiovasc Imaging,
January 1, 2008;
9(1):
196 - 198.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Shindo, K. Kubota, and M. Matsumoto
Thromboembolism from the noncoronary cusp of a patient with a normal aortic valve and protein C deficiency
J. Thorac. Cardiovasc. Surg.,
May 1, 2006;
131(5):
1171 - 1172.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. Barandon, P. Clerc, C. Chauvel, and P. Plagnol
Native aortic valve thrombosis: a rare cause of acute ischemia of the lower limb
Interact CardioVasc Thorac Surg,
December 1, 2004;
3(4):
675 - 677.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
