Prosthetic Mitral Valve Thrombosis: Can Fluoroscopy Predict the Efficacy of Thrombolytic Treatment?

Abstract

Background-Thrombolysis (T) is an effective therapy for prosthetic valve thrombosis (PVT). Debate still exists as to which clinical or noninvasive finding best predict the result of T. The aim of the study was to investigate the role of fluoroscopy (F) to predict efficacy of T in pts with mitral PVT. Methods-We evaluated 17 consecutive pts with bileaflet mitral PVT. F criteria for PVT were: abnormal disc motion and calculated opening angle Ͼ25°. T was carried out with tissue-type plasminogen activator (tPA; 100 mg over 3 hours followed by heparin infusion for 24 hours) and was considered successful when normalization of leaflet motion and opening angle occurred. Results were evaluated according to symptom duration (Ͻ21 days, early PVT; Ͼ21 days, late PVT) and to F pattern of PVT (blocked leaflet versus hypomobile leaflet). Results-F showed disc motion alteration in 24 of 34 leaflets: 8 leaflets were blocked, whereas 16 were hypomobile. Early (12.7Ϯ6.1 days, range 3-21) and late (113Ϯ114 days, range 28 -365) PVT was present in 8 and 7 pts, respectively. Thrombolysis was successful in 20 of 24 leaflets. Blocked leaflet fully recovered only in early PVT (nϭ4) pts, whereas they remained blocked in late PVT (nϭ4). On the contrary, in all of the cases with hypomobile leaflet, disc motion normalized regardless duration of symptoms and extent of disc motion reduction. Interestingly, 4 leaflets with late PVT was diagnosed as blocked by trans-thoracic (TTE). F showed a residual disc movement in all: they fully recovered after T. Two pts with late PVT had both leaflets affected (1 blocked ϩ1 hypomobile); although blocked leaflet did not respond to T, the normalization of hypomobile significantly improved clinical condition. Conclusions-F can predict result of T in mitral PVT. PVT with F evidence of hypomobile leaflet always recovers regardless of symptom duration and extent of disc motion reduction, suggesting that the small amount of thrombus needed to interfere with discs motion in bileaflet prostheses remains sensitive to T even after a long time. PVT with F evidence of blocked leaflet has a favorable response to T only in case of early PVT. Late PVT with blocked leaflet does not respond to T, suggesting a larger and stratified thrombus and the coexistence of pannus and, in our series, always required surgery. However, if a hypomobile leaflet coexists, T may be used to restore normal movement of hypomobile leaflet so that to improve patient clinical and hemodynamic condition before operation.

Serial Fluoroscopy Guided Fibrinolytic Therapy in a Patient with Obstructive Mechanical Aortic Valve Thrombosis

“…In the case of bileaflet valves, the disks can be directly visualised, and opening and closing angles measured using a tangential view (5,6) . Fluoroscopy is the most widely used method for making the diagnosis of stuck valves (7) .…”

Trombose aguda de prótese mecânica mitral tratada efetivamente com trombólise

“…It characterizes the type, size and location of the thrombus, thus helping to choose the most appropriate treatment 5 .…”

“…The successful use of fibrinolytic agents in the treatment of thrombosis of Starr-Edwards prosthesis in the tricuspid position was first described by Luluaga et al 4 in 1971. Currently, thrombolytic therapy has been documented as an effective alternative treatment, and is the first choice for right chambers [3][4][5][6] . However, thrombolysis remains a debatable treatment for aortic and mitral valve diseases due to the risk of embolic and hemorrhagic events and recurrences 5 .…”

“…Currently, thrombolytic therapy has been documented as an effective alternative treatment, and is the first choice for right chambers [3][4][5][6] . However, thrombolysis remains a debatable treatment for aortic and mitral valve diseases due to the risk of embolic and hemorrhagic events and recurrences 5 . We report a case of thrombosis in mechanical mitral valve prosthesis successfully treated with thrombolysis.…”

Treatment of mechanical valve thrombosis during pregnancy

“…2 Transthoracic echocardiogram with Doppler provides hemodynamics, valve gradient and area, and visualization of the valve. However, normal mechanical prosthetic valve gradient should be considered since different types of mechanical prosthetic valve accommodate variable valve gradients.…”