Misconceptions, diagnostic challenges and treatment opportunities in bioprosthetic valve thrombosis: lessons from a case series

Pislaru, Sorin V.; Hussain, Imad; Pellikka, Patricia A.; Maleszewski, Joseph J.; Hanna, Richard D.; Schaff, Hartzell V.; Connolly, Heidi M.

doi:10.1093/ejcts/ezu201

Cited by 99 publications

(61 citation statements)

References 22 publications

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“…Previously reported cases of early valve thrombosis after AVR, excluding patients on anticoagulation or thrombolytic therapy, 6-8 are summarized in Table 1. 3,5,[9][10][11][12][13][14][15][16][17][18][19][20] Porcine aortic valves were used in all but 2 patients, in whom a pericardial valve was used. 9, 15 Brown and colleagues 5 reported no thrombosis cases in stented pericardial valves or stentless porcine valves.…”

Section: Discussionmentioning

confidence: 99%

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Early stenosis of an aortic porcine bioprosthesis due to thrombosis: Case report and literature review

Dohi

Doi

2015

The Journal of Thoracic and Cardiovascular Surgery

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Section: Discussionmentioning

confidence: 99%

“…22,23 The largest study on bioprosthetic valve thrombosis reported a peak incidence 13 to 24 months after surgical implantation. 20 The literature review found that approximately half of the cases occurred after 13 months.…”

Section: Discussionmentioning

confidence: 99%

Early stenosis of an aortic porcine bioprosthesis due to thrombosis: Case report and literature review

Dohi

Doi

2015

The Journal of Thoracic and Cardiovascular Surgery

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“…The most important cause of prosthetic valve thrombosis is inadequate anticoagulation, which is more common with mechanical valves, but thrombosis can occur with bioprostheses long after implantation [23,26,27].…”

Section: Thrombosis and Pannus Formationmentioning

confidence: 99%

Postoperative Complications after Surgical Aortic Valve Replacement

Koo

Lee

Anh

et al. 2017

Cardiovasc Imaging Asia

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Aortic valve replacement is one of the most common major cardiac surgeries worldwide. Despite improvements in surgical techniques, postoperative complications after aortic valve surgery remain a source of substantial morbidity and mortality. Although transthoracic echocardiography and transesophageal echocardiography have been used for routine surveillance of prosthetic heart valves, computed tomography (CT) has played an important role with echocardiography in the diagnosis, treatment, and follow-up of patients after valve replacement. CT has the advantage of evaluating the extent of disease, such as paravalvular dehiscence, abscess, and pseudoaneurysm, in aortic prosthetic valves. In this article, we review the various image findings of postoperative complications after aortic valve replacement detected on CT.

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“…17 Thrombosis of bioprosthetic valves is increasingly recognized as a cause of obstruction, and findings at echocardiography that suggest thrombosis have been proposed. 4,18 MDCT seems promising for evaluation of cases of suspected thrombosis of bioprosthetic valves 19 because image quality is generally good with fewer artifacts. Comparison of these modalities is an appropriate area for future study.…”

Section: See Article By Gündüz Et Almentioning

confidence: 99%

“…2,3 However, it can occur with bioprostheses and may develop long after implantation. 4 Pannus is a more chronic process associated with ingrowth of tissue, causing obstruction. 5 Distinguishing between thrombus and pannus as a cause of obstruction is important because thrombus can potentially be treated with fibrinolysis, whereas pannus requires surgical intervention to relieve the obstruction.…”

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confidence: 99%

Prosthetic Valve Thrombus Versus Pannus

Bonnichsen

Pellikka

2015

Circ: Cardiovascular Imaging

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Bonnichsen and Pellikka Imaging Prosthetic Valve Thrombus vs Pannuswas possible, the 64-slice MDCT attenuation value of the periprosthetic mass was useful in differentiating between thrombus and pannus. If the HU value of the mass was ≥145, pannus was diagnosed with a high sensitivity and specificity.Response to thrombolysis could also be predicted using the HU value, with complete lysis obtained in all masses with a value <90. The authors suggest that these values could be used clinically to guide treatment, with masses with a HU value ≥145 going directly to surgery and masses with a HU value <90 receiving thrombolytics. These findings are encouraging and should be confirmed in larger prospective studies.Further information about the group of patients studied would be of interest. Was imaging performed as a part of routine surveillance or was prosthetic valve dysfunction suspected? If it was suspected, what was the basis for suspicion? Did the patients have cardiac symptoms, murmurs, embolic events, or low international normalized ratios? Were all receiving low-dose aspirin, which is recommended in addition to vitamin K antagonists in patients with mechanical heart valves? 9All patients in the study also had a TEE, and the authors appropriately point out that TEE is good at detecting masses likely to be thrombus, including in this study. They suggest that the addition of MDCT may be clinically useful in patients where TEE does not show a mass or if there is suspicion for pannus on TEE. If echocardiography clearly shows evidence of thrombus in the appropriate clinical setting, MDCT is likely unnecessary and exposes the patient to additional risks including iodinated contrast and radiation exposure. However, if echocardiography reveals obstruction of the valve but the mechanism is unclear, the additional information obtained by MDCT may save the patient from an operation if fibrinolysis can be performed for thrombus or may save the patient from the risks of fibrinolysis in the case of pannus. Threedimensional TEE has the potential to provide additive information to that obtained by standard TEE imaging and may play a useful role in the evaluation of possible prosthetic valve thrombosis, 16 but was not evaluated in the current study. Diagnostic images could not be obtained in 4 patients. Older generation mechanical valves are particularly known to cause significant artifact.12 Because artifact is also a problem for echocardiography, which is also currently used to guide many interventional procedures, manufacturers of prosthetic valves and devices would benefit patients by using materials that are more suitable for imaging.With multiple imaging modalities now available, it is critical to understand the strengths and weaknesses of each modality to select the most appropriate test that provides the necessary information to answer the clinical question in a costeffective manner and expose the patient to the least amount of risk. MDCT holds potential to provide additional information about the mechanism of prosthetic ...

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Misconceptions, diagnostic challenges and treatment opportunities in bioprosthetic valve thrombosis: lessons from a case series

Abstract: BPVT may occur late after surgical implantation. VKA therapy resulted in haemodynamic and clinical improvement with minimal risk, and should be considered the first-line therapy in haemodynamically stable patients. Echocardiographic criteria for improving BPVT diagnosis are proposed.

Cited by 99 publications

References 22 publications

Early stenosis of an aortic porcine bioprosthesis due to thrombosis: Case report and literature review

Early stenosis of an aortic porcine bioprosthesis due to thrombosis: Case report and literature review

Postoperative Complications after Surgical Aortic Valve Replacement

Prosthetic Valve Thrombus Versus Pannus

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