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Ann Thorac Surg 2000;70:2182-2183
© 2000 The Society of Thoracic Surgeons

Update

Prosthetic valve obstruction: thrombolysis versus operation

Updated in 2000

Nicola Vitale, MD, PhDa,b, Attilio Renzulli, MDa, Luigi de Luca Tupputi Schinosa, MDa, Maurizio Cotrufo, MDa

a Department of Cardiac Surgery, Medical School, University of Bari, Bari, Italy
b Department of Cardiothoracic Sciences, Vincenzo Monaldi Hospital, Medical School, Second University of Naples, Naples, Italy

Address reprint requests to Dr Vitale, Istituto di Cardiochirurgia, Policlinico, Piazza Giulio Cesare 11, 70124 Bari, Italy
e-mail: Nicola.Vitale{at}excite.co.uk

Abstract

As Originally Published in 1994:



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Six years have passed since the publication of our original article. The initial experience demonstrated the utility of thrombolysis in prosthetic valve obstruction. Since that time we have gained a deeper knowledge in all aspects of valve obstruction so that indications, benefits, and limits of either surgical and fibrinolytic treatment have been appreciated [1, 2].

So far we have observed 120 prosthetic valve obstructions (105 mitral, 15 aortic). Ninety-three patients underwent redo valve replacement and 24 patients received thrombolysis. Thrombolysis was successful in all but 1 case.

The main point is to distinguish pannus from thrombus. For this purpose we still consider the following criteria valid indications for thrombolysis: transesophageal echocardiographic (TEE) evidence of clots on the valve and chambers, and slightly reduced disc excursion. Thrombolysis in tilting disc valves is reserved only for nonobstructive thrombosis, because obstructive thrombosis in this valve model is generally sustained by pannus [1]. On the other hand, bileaflet valves are more prone to primary thrombosis than fibrous tissue overgrowth [1] and sometimes the obstruction affects only one leaflet [1]. Therefore thrombolysis can be considered also when a reduced leaflet excursion is noted [1, 3].

Multiplane TEE is the best investigative tool for the diagnosis of valve obstruction [4]. It is also useful to monitor thrombolysis outcome [2, 4]. Although some TEE features have been identified to differentiate pannus from thrombus [5], they are not totally reliable and the distinction is still left to the expertise of the echocardiographer. Clinical history and presentation are also helpful.

Recombinant tissue-type plasminogen activator was used as it requires only a short course of infusion. A 25% rate of transient embolic complications was observed during treatment. Although no permanent damage resulted because of a secondary fibrinolysis, we acknowledge that the complication rate is high. In our series all 3 patients with an aortic valve experienced embolism during thrombolysis. It can be speculated that while thrombotic material from the mitral valve remains in the left cardiac chambers long enough to be dissolved completely, clot debris from the aortic valve moves into the bloodstream immediately after detachment and dissolves only during embolization. As a consequence thrombolysis for aortic valve thrombosis may carry a higher embolic risk. We never had any bleeding complications. No heparin, either in infusion or subcutaneously, is commenced after thrombolysis. Warfarin is restarted the same evening after thrombolysis and dypiridamole is added.

We do not agree with the policy of carrying out thrombolysis in patients hemodynamically too unstable to undergo operation [4]. In this subset of patients prosthetic valve replacement is the best option, because thrombolytic drugs take several hours to be effective, especially heparin [4]; therefore the patient will deteriorate even further, dramatically increasing the risk of redo operation if fibrinolysis fails. Also, results with re-replacement have improved over the years, as with any redo procedures.

In conclusion, we consider thrombolysis a valid treatment for nonobstructive prosthetic thrombosis only. In the future we may witness an increase in the number of thrombolyses with a decrease of prosthetic valve replacements, as bileaflet valves are the most widely implanted valve prostheses. Any time a blocked disc is detected pannus should be suspected, and the patient referred for operation. Patients should also be well informed of the risks of thrombolysis, especially embolism.

References

  1. Vitale N., Renzulli A., Agozzino A., Tedesco N., de Luca Tupputi Schinosa L., Cotrufo M. Obstruction of mechanical mitral prostheses: analysis of pathologic findings. Ann Thorac Surg 1997;63:1101-1106.[Abstract/Free Full Text]
  2. Renzulli A., Vitale N., Caruso A., Dialetto G., de Luca Tupputi Schinosa L., Cotrufo M. Thrombolysis for prosthetic valve thrombosis: indications and results. J Heart Valve Dis 1997;6:212-218.[Medline]
  3. Silber H., Khan S.S., Matloff J.M., Chaux A., DeRobertis M., Gray R. The St Jude valve: thrombolysis as the first line therapy for cardiac valve thrombosis. Circulation 1993;87:30-37.[Abstract/Free Full Text]
  4. Lengyel M., Fuster V., Keltal M., et al. Guidelines for management of left-sided prosthetic valve thrombosis: a role for thrombolytic therapy. J Am Coll Cardiol 1997;30:1521-1526.[Abstract]
  5. Barbetseas J., Naguegh S.F., Pitsavos C., Toutouzas P.K., Quinones M.A., Zoighbi W.A. Role of trans-esophageal echocardiography in differentiating pannus from thrombus in obstructed prosthetic valves. J Am Coll Cardiol 1998;31(Suppl 1):463A-464A.



This article has been cited by other articles:


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Transesophageal echocardiography improves risk assessment of thrombolysis of prosthetic valve thrombosis: results of the international PRO-TEE registry
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