Ann Thorac Surg 2007;84:1424
© 2007 The Society of Thoracic Surgeons
Correspondence
Importance of Long-Term Anticoagulation in Both Prosthetic and Biological Tricuspid Valve Replacements
Isma Rafiq, MB, MRCP,
Leisa J. Freeman, MB, ChB,
Sheila Wood
Department of Cardiology, Norfolk and Norwich University NHS Hospital, Colney Lane, Norwich, NR4 7UZ United Kingdom
(Email: leisa.freeman{at}nnuh.nhs.uk).
To the Editor:
We concur with the article of Chang and colleagues [1] that tricuspid valve replacements (TVR) have a high attrition rate and co-morbidity. The high rate of thrombosis is of particular importance as demonstrated by a recent case seen in our institution. The patient first presented at the age of 15 months with failure to thrive and was found to have an atrial septal defect and multiple ventricular septal defects. Repair of her septal defects was undertaken at the age of 2 years, but this resulted in damage to her tricuspid valve (TV), which led to a 19-mm Hancock tricuspid valve (Medtronic Inc, Minneapolis, MN) replacement later in the same year. Five years later, valvular stenosis caused by pannus ingrowth required a Bjork Shiley TV (Shiley Inc, Irvine, CA) replacement. Two years later, at 9 years of age, the TVR had significant thrombus develop, and she had a further valve replacement (this time with a 21-mm St. Jude valve [St. Jude Medical Inc, St. Paul, MN]). Further progressive pannus ingrowth led to a larger 25-mm St. Jude TV replacement at the age of 14 years. Pannus ingrowth again led to increasing tricuspid stenosis (with symptoms of systemic venous congestion) requiring a fifth TVR (sixth thoracotomy) when she was aged 29 years. A 25-mm Carpentier-Edwards bioprosthetic valve (Baxter Healthcare Corp, Irvine, CA) was inserted. She was anticoagulated for 3 months postoperatively. However, 5 months postoperatively, a new mid-diastolic murmur was heard and despite being asymptomatic, an echocardiogram demonstrated significant thrombus, not only around the valve struts but also murally in the right ventricular outflow tract. The TV valve area was reduced and the trans-tricuspid gradient increased (see Table 1). This was treated aggressively with intravenous urokinase and oral sodium warfarin. Five months later, re-imaging has demonstrated complete resolution of the thrombus and normalization in her trans-tricuspid valve Doppler gradient. Valve replacements in the tricuspid position have low flow with high potential to thrombotic obstruction. There seems to be a strong case for long-term anticoagulation with an international normalized ratio between 3 and 4, even in bioprosthetic valves.
View this table:
[in this window]
[in a new window]
|
Table 1 Echocardiographic Data From a Patient With Carpentier Edwards Tricuspid Valve Replacement: Postoperative, Post-Cessation of Warfarin, Post-Thrombolysis and Late Follow-Up
|
|
 |
References
|
|---|
- Chang BC, Lim SH, Yi G, et al. Long-term clinical results of tricuspid valve replacement Ann Thorac Surg 2006;81:1317-1323discussion 1323–4.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
S. Lee and B.-C. Chang
Reply
Ann. Thorac. Surg.,
October 1, 2007;
84(4):
1425 - 1425.
[Full Text]
[PDF]
|
|
|
Top
References