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European Journal of Echocardiography Advance Access published online on February 13, 2008
European Journal of Echocardiography, doi:10.1093/ejechocard/jen072
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org

Successful fibrinolytic treatment in an old patient with acute aortic prosthetic thrombosis

Ergün Baris Kaya*, Ugur Kocabas, Kudret Aytemir and Lale Tokgözoglu

Cardiology Department, Faculty of Medicine, Hacettepe University, Sihhiye, Ankara 06100, Turkey

Received 6 November 2007; .

* Corresponding author: Ergazi Mah. Batikent Bulvari. Mitas-Çagdas Sitesi 9/2, Batikent, Ankara, Turkey. Tel: +90 312 3051780; fax: +90 312 3054137. E-mail address: doctorkaya{at}yahoo.com; ekaya{at}hacettepe.edu.tr


   Abstract
Top
 Abstract
Case report
 Discussion
 Conclusion
 References
 
Thrombosis of mechanical heart valve prosthesis is a rare fatal complication after heart valve replacement. This report describes an old female patient with aortic prosthetic valve thrombosis who had a successful fibrinolytic treatment.

Keywords: Prosthetic heart valve; Thrombosis; Fibrinolytic treatment

Thrombosis is a well-known fatal complication of prosthetic mechanical heart valves, with an incidence of 0.03 to 4.3% per patient year, and varies depending on the location of prosthesis (most frequent in tricuspid, less frequent in mitral and aortic positions).1 The surgical operation has been the traditional management strategy for prosthetic valve thrombosis (PVT). However, mortality rate is high during surgery, depending mainly on patient's functional status. Fibrinolytic treatment is an alternative therapy to surgery and is considered a first-line treatment of choice for right-sided PVT.2 However, because of the high risk of cerebral thrombo-embolism, the use of fibrinolytic therapy for left-sided PVTs remains controversial and only reserved for surgically high-risk patients. We hereby present the case of an old woman with pulmonary oedema in whom transthoracic echocardiography (TTE) revealed thrombosis of aortic prosthetic valve.


   Case report
Top
 Abstract
 Case report
Discussion
 Conclusion
 References
 
An 82-year-old woman presented with a 1 week history of dyspnoea, which had progressively worsened for the last 3 days. She had undergone aortic valve replacement for severe stenosis with a bi-leaflet St Jude mechanical heart valve prosthesis 10 years ago. On admission, the patient was dyspnoeic and orthopnoeic at rest. She did not have angina, palpitation, or fever. She had non-productive cough for 1 week. Her medical history revealed that she had type 2 diabetes mellitus, hypertension, and thrombotic stroke 2 years ago. Her drug treatment includes insulin, oral antidiabetics, angiotensin-converting enzyme-inhibitor, aspirin, and oral anticoagulant (warfarin sodium). However, she did not use warfarin regularly for the last weeks. In physical examination, blood pressure was 150/90 mmHg and heart rate was 110 bpm. She was dyspnoeic and tachypnoeic. Auscultation of the chest revealed moist rales from base to mid-zones of each lung. Heart auscultation revealed 2/6 systolic murmur at aortic area and 3/6 grade early-diastolic murmur at left parasternal border. Her electrocardiogram showed sinus tachycardia and non-specific intraventricular conduction delay. Chest radiography demonstrated pulmonary congestion. Her complete blood count showed anaemia (Hb: 11.2 g/dL). The international normalized ratio (INR) was low (1.3) (target range 2.5–3.5). The results of other haematological, blood chemistry, and cardiac enzyme analyses were within normal limits.

Transthoracic echocardiography with spectral Doppler recording of transvalvular blood flow was performed using a Vivid Five instrument (GE-Vingmed Ultrasound AS, Horten, Norway) with a multifrequency transducer. Transthoracic echocardiography revealed normal left and right ventricular dimensions. Left ventricular ejection fraction was found to be normal. An obstructive thrombus was seen in aortic mechanical valve (Figure 1). The pressure gradient across aortic valve was 80 mmHg (peak)/45 mmHg (mean). A 2–3/4 grade aortic insufficiency was recorded. Transoesophageal echocardiography (TEE) was planned, but the patient did not tolerate the procedure and she refused to do so.


Figure 1
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  		Figure 1 Transthoracic echocardiographic apical view of the thrombus formation on the prosthetic aortic valve and aortic regurgitation. Ao, aorta; LA, left atrium; LV, left ventricle.

 
On the basis of clinical and echocardiographic findings, the surgery was planned for the patient, but she refused the surgery. Then streptokinase at a starting dose of 250 000 U was given for 1 h, followed by continuous infusion at a rate of 100 000 U/h for the next 24 h. Twelve hours after initiation of fibrinolysis, the patient's dyspnoea began to resolve. After completion of fibrinolytic treatment, she was quite normal without any complaints. Control TTE revealed the resolution of thrombosis, and the pressure gradient was found to be 30/12 mmHg (peak, mean) (Figure 2). The patient was discharged from the hospital in good clinical condition. Oral anticoagulation with warfarin sodium with target INR values of 2.5–3.5 and concomitant use of aspirin at a dosage of 100 mg/day was strongly recommended to the patient.


Figure 2
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  		Figure 2 Transthoracic echocardiographic apical view of prosthetic aortic valve after successful fibrinolytic treatment. Ao, aorta; LA, left atrium; LV, left ventricle.

 

   Discussion
Top
 Abstract
 Case report
 Discussion
Conclusion
 References
 
Thrombosis is a major complication after prosthetic heart valve replacement, leading to an increased morbidity and mortality. Although new valve designs and progress in operating techniques have improved the results of valve replacement surgery, thrombo-embolic complications remain as an important issue, mostly because of inadequate anticoagulant therapy. The incidence of PVT can be as high as 13% in the first year in any valve location and even can be 20% for tricuspid valve position.3 The incidence of left-sided PVT varies between 0.5 and 6% per patient-year.4

Emergent or urgent surgery has been the traditional treatment of choice for mechanical valve thrombosis, depending on the clinical status of the patient for many years. However, the mortality rate associated with valve surgery can be as high as 69%, varying with the functional status of the patient.5 That is why new alternative therapeutic strategies, such as fibrinolytic treatment, become promising modality. However, there are no randomized trials comparing the results of surgery with fibrinolysis in PVT. Vitale et al.6 compared the results of surgery with thrombolysis in 28 patients, of which 20 had surgical treatment, with 1 death. Eight cases (seven mitral and one aortic prosthetic thrombosis) were treated with fibrinolytic therapy and all responded well without deaths or neurological complications. The authors of this small, uncontrolled study reported that thrombolysis was effective in selected patients. There is general agreement on the indications for fibrinolysis in patients with right-sided heart valve thrombosis, because the success rate is especially high and the risk of cerebrovascular accident absent.7 There is no such consensus in cases of PVT in the mitral and aortic positions. Fibrinolytic treatment for the left-sided PVT has been recommended to critically sick patients with functional class III or IV, and high surgical operative risk as class IIb recommendation (level of evidence: B) by ACC/AHA.7 Lengyel et al.8 reported the results of more than 200 published reports of left-sided prosthetic valve fibrinolysis showing an 82% initial success rate, a stroke rate of 5–10%, with 6% death, 5% major bleeding, an overall thrombo-embolism rate of 12 and 11% of recurrent thrombosis. Roudaut et al.9 reported their centre study of 127 instances of PVT treated with fibrinolysis over 22 year period. Complete resolution of haemodynamic abnormalities was observed only in 70.9% of cases, and the mortality was reported to be 11.8%. Other studies also showed similar results for fibrinolytic treatment in patients with PVT.10–12 A meta-analysis including 515 cases reported an initial success rate of 84%, a mortality of 5%, bleeding complications in 3%, and systemic embolism in 9%.13

The most important complications of fibrinolytic therapy are thrombo-embolic events and haemorrhage. Intracranial haemorrhage deserves special mention, as it is one of the most severe and feared complications of fibrinolytic therapy. The incidence of cerebral haemorrhage has been widely evaluated in large multicentre trials of fibrinolytic treatment of acute myocardial infarction and found to be <1%. In studies of thrombolytic therapy for PVT, the cerebral haemorrhage rate fluctuated between 0 and 3%.13,14 Older age is an important risk factor for intracranial bleeding.15 Although the elderly constitute a minority of the general population, they are the fastest growing segment of the population. All studies mentioned above included patients who were younger than 80 years of age. The decision to use fibrinolytic therapy in older patients should be based on an estimate of the patient's underlying risk without treatment, the expected benefit of the treatment, and the risk of the therapy. In general, the higher the underlying risk, the more benefit that can be gained. Our patient, who is 82 years of age, is a good example of successful fibrinolytic treatment for aortic PVT and shows the efficacy of this therapy in older patients who were not included in most of the PVT registries.

Transthoracic echocardiography is the most widely used diagnostic tool in patients with suspected PVT.16 However, TEE can provide more accurate images than TTE and, when available, is the best diagnostic tool to determine alterations in the occlusive mechanism or the existence of valvular thrombotic masses. In addition, TEE may clearly show the restricted prosthetic valve motion and the size, location, and mobility of the thrombosis. However, TEE is a semi-invasive technique, and it may be difficult to perform in old patients, especially serial TEE examinations are needed to evaluate the response to treatment. In these conditions, transprosthetic pressure gradients can be easily estimated by TTE Doppler examination. In addition, TTE can also detect an altered flow pattern suggestive of intrinsic prosthetic failure, alterations in the mobility of the occlusive system, or the presence of a thrombotic mass adherent to the prosthesis. The relief of haemodynamic obstruction by thrombolysis can also be monitored simply by transthoracic Doppler echocardiography.


   Conclusion
Top
 Abstract
 Case report
 Discussion
 Conclusion
References
 
Prosthetic valve thrombosis is one of the most serious complications of a mechanical heart valve. Fibrinolytic therapy is effective in PVT. This case is an example of successful fibrinolytic treatment in an old female patient with aortic PVT, showing the effectiveness of this type of treatment in high-risk patients.

Conflict of interest: none declared.


   References
Top
 Abstract
 Case report
 Discussion
 Conclusion
 References
 

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  2. Lengyel M, Horstkotte D, Voller H, Mistiaen WP. Recommendations for the management of prosthetic valve thrombosis. J Heart Valve Dis (2005) 14:567–75.[Web of Science][Medline]
  3. Caceres-Loriga FM, Perez-Lopez H, Santos-Gracia J, Morlans-Hernandez K. Prosthetic heart valve thrombosis: pathogenesis, diagnosis and management. Int J Cardiol (2006) 110:1–6.[CrossRef][Web of Science][Medline]
  4. Vongpatanasin W, Hillis LD, Lange RA. Prosthetic heart valves. N Engl J Med (1996) 335:407–16.[Free Full Text]
  5. Deviri E, Sareli P, Wisenbaugh T, Cronje SL. Obstruction of mechanical heart valve prostheses: clinical aspects and surgical management. J Am Coll Cardiol (1991) 17:646–50.[Abstract]
  6. Vitale N, Renzulli A, Cerasuolo F, Caruso A, Festa M, de Luca L, et al. Prosthetic valve obstruction: thrombolysis versus operation. Ann Thorac Surg (1994) 57:365–70.[Abstract]
  7. Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, et al. ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease. J Am Coll Cardiol (2006) 48:e1–48.[Free Full Text]
  8. Lengyel M, Fuster V, Keltai M, Roudaut R, Schulte HD, Seward JB, et al. Guidelines for management of left-sided prosthetic valve thrombosis: a role for thrombolytic therapy. Consensus Conference on Prosthetic Valve Thrombosis. J Am Coll Cardiol (1997) 30:1521–6.[Abstract]
  9. Roudaut R, Lafitte S, Roudaut MF, Courtault C, Perron JM, Jais C, et al. Fibrinolysis of mechanical prosthetic valve thrombosis: a single-center study of 127 cases. J Am Coll Cardiol (2003) 41:653–8.[Abstract/Free Full Text]
  10. Gupta D, Kothari SS, Bahl VK, Goswami KC, Talwar KK, Manchanda SC, et al. Thrombolytic therapy for prosthetic valve thrombosis: short- and long-term results. Am Heart J (2000) 140:906–16.[CrossRef][Web of Science][Medline]
  11. Caceres-Loriga FM, Perez-Lopez H, Morlans-Hernandez K, Facundo-Sanchez H, Santos-Gracia J, Valiente-Mustelier J, et al. Thrombolysis as first choice therapy in prosthetic heart valve thrombosis. A study of 68 patients. J Thromb Thrombolysis (2006) 21:185–90.[CrossRef][Web of Science][Medline]
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  13. Lopez HP, Caceres Loriga FM, Hernandez KM, Sanchez HF, Gonzalez Jimenez N, Marrero Mirayaga MA, et al. Thrombolytic therapy with recombinant streptokinase for prosthetic valve thrombosis. J Card Surg (2002) 17:387–93.[Web of Science][Medline]
  14. Lengyel M. Management of prosthetic valve thrombosis. J Heart Valve Dis (2004) 13:329–34.[Web of Science][Medline]
  15. Brass LM, Lichtman JH, Wang Y, Gurwitz JH, Radford MJ, Krumholz HM. Intracranial hemorrhage associated with thrombolytic therapy for elderly patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project. Stroke (2000) 31:1802–11.[Abstract/Free Full Text]
  16. Barbetseas J, Nagueh SF, Pitsavos C, Toutouzas PK, Quinones MA, Zoghbi WA. Differentiating thrombus from pannus formation in obstructed mechanical prosthetic valves: an evaluation of clinical, transthoracic and transesophageal echocardiographic parameters. J Am Coll Cardiol (1998) 32:1410–7.[Abstract/Free Full Text]

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