Ann Thorac Surg 2006;81:1911-1912
© 2006 The Society of Thoracic Surgeons
How to do it
The Blower: A Useful Tool to Complete Thrombectomy of the Mechanical Prosthetic Valve
Aziz Alami Aroussi, MD,
Ibrahim Mohamed Sami, MD,
Alain Leguerrier, MD,
Jean Phillippe Verhoye, MD
*
Department of Thoracic and Cardiovascular Surgery, University Hospital Ponchaillou, Rennes, France
Accepted for publication February 23, 2005.
* Address correspondence to Dr Verhoye, CTCV, Hôpital Ponchaillou, 2 rue Henri Le Guilloux, Rennes, 35033 France (Email: jean-philippe.verhoye{at}chu-rennes.fr).
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Abstract
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Thrombectomy could be an excellent approach on one condition (ie, that all parts of the thrombus are removed). We propose to use a tool (ie, the blower) to complete thrombectomy of the prosthetic mechanical valve. The blower is a vaporizer that mixes air and heparinized saline with regulator of flow and proportion used in beating heart surgery. For thrombectomy, we have modified the air-water mixing part and intensity until we obtained a jet that enabled us to remove the micro thrombus that covered the prosthetic valve and surrounding tissues. The blower completely cleaned the prosthetic valve. With this tool, thrombectomy seems easier, more complete, and more reliable with the advantages of short cross-clamping time.
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Introduction
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Prosthetic valve thrombosis is defined as any thrombus, in the absence of infection, attached to or near an operated valve, occluding part of the blood flow or interfering with valvular function [1]. This rare but life-threatening complication of prosthetic valve replacement is dependent on valve design, location (mitral position), and patient compliance with oral anticoagulation. Although this complication can be found with any type of valve prosthesis, even with anticoagulation, 1% of patients with mechanical valves in the mitral position may have this complication [2]. Thrombolysis, thrombectomy, or prosthetic replacements are currently available options. Redo replacement of the thrombosed prosthesis may imply long cross clamping and cardiopulmonary bypass times. It should be restricted to cases of extensive pannus or if mechanical damage is found. When the event is related to an inadequate level of anticoagulation, thrombectomy could be an excellent approach for the condition when all parts of the thrombus are removed. We propose to use a tool (ie, the blower) to complete thrombectomy of the prosthetic valve.
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Technique
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The blower is a vaporizer that mixes air and heparinized saline with a regulator of flow and proportion. Used in beating heart conditions, the resulted flow is smooth, just sufficient to clean the opened coronary vessel from blood. We have used this tool to improve the thrombectomy of prosthetic mitral valve thrombosis during a surgical redo.
In the context of thrombectomy, we have modified the air-water mixing part and intensity until we obtained a jet able to remove the micro thrombi that covers the prosthetic valve, especially at the hinges of the mechanical leaflets. The oxygen pressure is 3, 5-5 barr.
The oxygen flow is 8 L/min, whereas the saline flow is adjustable according to the need, with a sterile roller tool connected to the blower tubing.
This technique was applied in a 68-year-old man for a mechanical St. Jude Medical Regent valve (St. Paul, MN) thrombosis implanted 7 years ago through a left atriotomy. Transthoracic echocardiography showed reduced leaflet motion, thrombi, and mean transprothetic pressure gradient at 25 mm Hg. The patient was operated on under normothermic cardiopulmonary bypass. Through a left atriotomy the prosthesis appeared occluded by recent thrombus formation. We carefully removed the thrombus. A big sized surgical needle was used for cleaning the prosthesis, but micro-thrombus were still attached in the rotation axe of the valve and the junction rigid stent of the valve. We used a ACCUMIST blower/mister (Minneapolis, MN) that completely cleaned the prosthetic valve (Fig 1). Aortic cross-clamping time was 15 minutes and total cardiopulmonary bypass time was 23 minutes. The postoperative course was uneventful.
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Comment
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The thrombectomy procedure is easy, fast, and safe. It does not damage the prosthesis by surface trauma, and it does not increase the risk of re-thrombosis [3]. The difficulty of thrombectomy is when a complete removal of the thrombus is necessary. This is not always easy to perform due to the adherent character of the thrombus, which can be attached to any part of the prosthetic valve and the native tissues surrounding it. In addition to the conventional removing of the thrombus using forceps and open-tipped suction, several techniques were described to complete the cleaning and to be certain that no thrombi were left in place. A conventional, stainless-steel curved sucker was used for thrombectomy, with great care taken not to damage the struts. A laryngeal mirror was also used to ensure that all the thrombus was cleaned off [2]. Vigorous washing and rinsing with a surgical needle and saline were used for cleaning of the device. Repeated clockwise leaflet rotation (in the rotatable valves) within the sewing ring was performed with the valve holder to clear all the quadrants and to facilitate full visualization of the ventricular aspect [4]. The appropriate valve tester was then used to confirm proper and free movements of both leaflets and unobstructed flow. Some authors suggested the use of the videoscope [5] for inspecting the ventricular cavity.
Despite these techniques, it is not easy to remove the small thrombi and especially the ones attached to leaflets hinges. The ability to give any shape to the blower permit to access and focus the cleaning jet at any part of the prosthetic valve (Figs 2, 3).
The technique of the blower is to provide a safe and focused jet able to eliminate any thrombotic material left in place with conventional thrombectomy techniques. If this technique is used in aortic position, one has to prevent coronary embolization by covering the ostia during the procedure.
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Fig 2. The ability to give any shape to the blower permits access and focuses the cleaning jet at any part of the prosthetic valve.
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With the blower, thrombectomy seems to be easier, more complete, and even more reliable with the advantages of short cross-clamping time, limiting the indications of replacements of the prosthetic valve to damage of circular pannus underlying the thrombus-like material or in the prosthetic mechanical damage.
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References
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- Edmunds LH, Clark RE, Cohn LH, et al. Guidelines for reporting morbidity and mortality after cardiac valvular operations J Thorac Cardiovasc Surg 1996;112:708-711.[Free Full Text]
- Tsai KT, Lin PJ, Chang CH, et al. Surgical management of thrombotic disc valve Ann Thorac Surg 1993;55:98-101.[Abstract]
- Venugopal P, Kaul U, Iyer KS, et al. Fate of thrombectomised Bjork-Shiley valvesa long-term cinefluoroscopic, echocardiographic, and hemodynamic evaluation. J Thorac Cardiovasc Surg 1986;91:168-173.[Abstract]
- Montero CG, Mula N, Brugos R, Tellez G, Figuera D. Thrombectomy of the Bjork-Shiley prosthetic valve revisitedlong-term results. Ann Thorac Surg 1989;48:824-828.[Abstract]
- Carrier M, Pellerin M, Dagenais F, et al. Video-assisted thrombectomy of mechanical prosthetic heart valves J Heart Valve Dis 1999;8:404-406.[Medline]
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Abstract
Introduction
