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Ann Thorac Surg 1999;67:1542-1543
© 1999 The Society of Thoracic Surgeons

Correspondence

An unexplained cluster of thrombosed bileaflet mechanical heart valve prostheses

Nilanjan Chaudhuri, FRCSEda, Mark St.J. Hickey, FRCSIa, Tomasz J. Spyt, FRCSa

a Department of Cardiothoracic Surgery, Glenfield Hospital, Groby Rd, Leicester LE3 9QP, United Kingdom

To the Editor

Between 1996 and 1998, we observed in our institution a cluster of thrombosed bileaflet mechanical heart valve prostheses (BMHV) in mitral position (Table 1) of unknown etiology. Until this, we had one episode of thrombosed bileaflet mitral heart valve prosthesis in 1993 in a patient with hypereosinophilic syndrome [1]. In the 5-year period between 1994 and 1998, 1,666 patients underwent 1,751 heart valve replacements in our hospital, 1,198 (68.4%) in aortic position and 543 (31%) in mitral position. In all, 1,000 BMHV were implanted. These included 497 St. Jude Medical (Minneapolis, MN), 438 CarboMedics (Austin, TX), 50 Bicarbon (Sorin Biomedica, Saluggia, Italy), 12 ATS open pivot valves (ATS Medical Ltd, Minneapolis, MN), and 3 Jyros (Manley Western UK Ltd, Chichester, UK). Out of 342 BMHV implanted in the mitral position, 192 were CarboMedics, 133 St Jude Medical, 10 Bicarbon (Sorin), and 7 ATS valves.


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  		Table 1. Relevant Characteristics of Patients With Thrombosed Bileaflet Prostheses

 
Four patients with BMHV had 5 thrombotic episodes (Table 1). All the thrombosed prosthetic valves were isolated valve replacements in the mitral position. One patient had 2 thrombotic episodes. All the patients underwent transesophageal echocardiography for definitive diagnosis. In 3 patients, there was primary thrombus, and 1 had mixed pannus and thrombus. All of them were anticoagulated with warfarin using the same regimen as other patients with mechanical valves in our institution. In one of the episodes, the International Normalized Ratio (INR) was < 2.5, and the rest had INR > 2.5. Three of the patients were in atrial fibrillation, and 1 was in sinus rhythm. One patient had a trial of thrombolysis, which failed. All the patients underwent urgent/emergency operation, and all of them survived. No specific etiology was found in any of the patients, and hematological indices were within expected limits. All the thrombosed valves were CarboMedics prostheses. There were no obvious structural defects of the prostheses on explantation.

Thus, the thrombosis rate for bileaflet valves prostheses in the mitral position was 0.54% per patient year (py) in general and 1.0% per py for CarboMedics valves. This is nearly double the thrombosis rate quoted for this valve in a recent clinical report [2]. For bileaflet valve prostheses as a whole, the thrombosis rate was 0.17% per py in our institution.

In conclusion, bileaflet heart valve prostheses remain reliable with low rates of thrombotic episodes. In the rare event of a patient with a thrombosed bileaflet valve, there is a good chance of survival with early surgery. The reason why thrombosis was seen with only one valve type remains unexplained. It is of concern, however, that there have been other clusters of thrombosed CarboMedics BMHV reported before elsewhere [3, 4].

References

  1. Arsiwala S., Peek G., Davies M., Sosnowski A., Firmin R. Hypereosinophilic syndrome: cause of prosthetic valve obstruction. J Thorac Cardiovasc Surg 1995;110:545.[Free Full Text]
  2. Burnett C, ed. The Clinical Report. Austin, TX: Sulzer CarboMedics 1998;10(2):2.
  3. Rosengart T.K., O’Hara M., Lang S.J., et al. Outcome analysis of 245 CarboMedics and St. Jude valves implanted at the same institution. Ann Thorac Surg 1998;66:1684-1691.[Abstract/Free Full Text]
  4. Wang S., Chu S.-H., Tsai C.-H., Lin F.-Y. Clinical use of CarboMedics and St. Jude Medical valves. Artifical Organs 1996;20:1299-1303.

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