Copyright © 2005, The European Society of Cardiology
Acute thrombosis of a prosthetic mitral valve
a2nd Cardiology Department, Onassis Cardiac Surgery Center, 356 Syngrou Avenue, Athens 17674, Greece
b3rd Department of Cardiac Surgery, Onassis Cardiac Surgery Center, 356 Syngrou Avenue, Athens 17674, Greece
Received 20 April 2005; received in revised form 5 July 2005; accepted after revision 27 July 2005.
philipc67{at}excite.com
* Corresponding author. Tel.: +30 210 7293 766; fax: +30 210 9493 336.
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Abstract |
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We report the case of a patient who was transferred to our hospital with acute thrombosis of a prosthetic mitral valve. Her admission INR was subtherapeutic. The transoesophageal echocardiographic images are presented. The patient underwent urgent reoperation and made a good recovery.
Keywords: Acute thrombosis; Prosthetic mitral valve; Transoesophageal echocardiography
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Case presentation |
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TopAbstractCase presentationDiscussionReferences |
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A 53-year-old lady was urgently transferred to our hospital on Christmas Day 2004, her 53rd birthday. She had undergone a mitral valve replacement for mitral stenosis with a Bjork–Shiley unileaflet valve 12 years previously. She had been asymptomatic until 24h before admission when she presented to her local hospital with sudden shortness of breath. A transthoracic echocardiogram there had raised the suspicion of prosthetic mitral valve thrombosis. She was given intravenous diuresis and sent to our hospital for further management.
On arrival the patient was severely breathless, sitting upright, and unable to speak. Clinical findings were consistent with severe pulmonary oedema. Her admission INR was low at 1.41. Transthoracic echocardiographic imaging was impossible due to the patient's breathlessness and obesity. She was becoming exhausted so we sedated, intubated, and ventilated her.
A transoesophageal echocardiogram (TOE) was then performed immediately and revealed a prosthetic mitral valve with restricted leaflet mobility and spontaneous contrast ("smoke") in the left atrium. There was an echodense mass (9x21mm) with reduced mobility on the atrial surface of the valve suggestive of a thrombus (Fig. 1). This was subsequently confirmed at operation. Color Doppler imaging with continuous wave (CW) flow demonstrated high transmitral velocities with a very elevated mean pressure gradient of 18mmHg (Fig. 2).
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She underwent urgent surgery. The prosthetic valve and thrombus were removed and replaced by a 25mm bileaflet ATS valve. Unfortunately, the thrombus was not photographed at the time of operation as this was an urgent case on Christmas Day and the medical photographer could not be summoned in time. The patient made an uncomplicated recovery and was discharged on her 15th postoperative day. She is currently asymptomatic with a well-controlled INR.
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Discussion |
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Acute prosthetic valve thrombosis (PVT) accounts for 1–6% of postoperative complications. It is most frequently due to faulty anticoagulation but has also been related to pannus formation.1,2 Prompt echocardiographic diagnosis is essential. The choice of immediate treatment remains controversial and includes reoperation, videoassisted thrombectomy, and thrombolysis.2–4 In a review of 200 PVT cases, thrombolysis is advised for high surgical risk patients with left-sided acute PVT.4 Thrombolysis is discontinued if there is no haemodymanic improvement and operation is indicated. The predicted probability for reoperation in prosthetic mitral valve thrombosis is higher with large (>27mm) bileaflet and older model (caged ball-disk) valves and lower with smaller models.2 Mortality at reoperation ranges between 0 and 69%, depends largely on functional class, and is highest in patients presenting in cardiogenic shock.4,5 Difficulties in establishing correct diagnosis and delay in immediate action contribute to severe clinical condition on admission.
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References |
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- Schulman S. Unresolved issues in anticoagulant therapy. J Thromb Haemost (2003) 1:1464–1470.[CrossRef][Web of Science][Medline]
- Rizzoli G., Guglielmi C., Toscano G., Pistorio V., Vendramin I., Bottio T., et al. Reoperations for acute prosthetic thrombosis and pannus: an assessment of rates, relationship and risk. Eur J Cardiothorac Surg (1999) 16:74–80.
[Abstract/Free Full Text] - Carrier M., Pellerin M., Dagenais F., Perrault L.P., Petitclerc R., Pelletier L.C. Videoassisted thrombectomy of mechanical prosthetic heart valves. J Heart Valve Dis (1999) 8:404–406.[Web of Science][Medline]
- Lengyel M., Fuster V., Keltai M., Roudaut R., Schulte H.D., Deward J.B., 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]
- Buttard P., Bonnefoy E., Chevalier P., Marcaz P.B., Robin J., Obadia J.F., et al. Mechanical cardiac valve thrombosis in patients in critical haemodynamic compromise. Eur J Cardiothorac Surg (1997) 11:710–713.[Abstract]
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