Prosthetic valve thrombosis (PVT) is a rare but serious complication of valve replacement, most often encountered with mechanical prostheses. The significant morbidity and mortality associated with this condition warrants rapid diagnostic evaluation. However, diagnosis can be challenging, mainly because of variable clinical presentations and the degree of valvular obstruction. Cinefluoroscopy (for mechanical valves) and transthoracic and transoesophageal echocardiography represent the main diagnostic procedures.

Although surgical treatment is usually preferred in cases of obstructive PVT, optimal treatment remains controversial. The different therapeutic modalities available for PVT (heparin treatment, fibrinolysis, surgery) will be largely influenced by the presence of valvular obstruction, by valve location (left- or right-sided), and by clinical status. Hence, treatment of an obstructive left-sided PVT will differ from that of non-obstructive or right-sided PVT. The purpose of this article is to review the physiopathology, diagnosis and treatment of PVT and to provide recommendations for management.

### Mechanical valve thrombosis

The incidence of obstructive PVT for mechanical valves varies between 0.3–1.3% patient years.1 Thromboembolic complications, including systemic emboli, are more frequent and occur at a rate of 0.7–6% patient years. Non-obstructive PVT is a relatively frequent finding in the postoperative period,2 with a reported incidence as high as 10% in recent transoesophageal echocardiography (TOE) studies. Although these are usually small non-obstructive thrombi, they underline the necessity of optimal anticoagulation in the postoperative period. According to a series of surgical interventions for PVT, the first postoperative year is marked by a 24% incidence of thrombosis, with a stable incidence between the second to fourth years of approximately 15%, with a subsequent decrease thereafter.3

### Bioprosthetic valve thrombosis

Thrombosis of a bioprosthetic valve4 is a rare occurrence when compared to mechanical prostheses. Bioprosthetic PVT is usually diagnosed in the early postoperative period, when endothelialisation of the suture zone is not yet complete. Hence, this has led …

/pdf/thrombosis-of-prosthetic-heart-valves-diagnosis-and-5863rcqm5e.pdf

Thrombosis of prosthetic heart valves: diagnosis and therapeutic considerations

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 >25°. 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 ( 21 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 (12.7±6.1 days, range 3–21) and late (113±114 days, range 28–365...

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

Prosthetic heart valve thrombosis (PVT) is a rare but serious complication with high morbidity and mortality. The optimal treatment of the PVT is controversial and depends on thrombus location and size, the patient's functional class, the risk of surgery or thrombolysis, and the clinician's experience. Although surgical therapy has been the traditional therapeutic approach, studies with low-dose and slow-infusion rates of thrombolytic agents have revealed excellent results. This article reviews the various treatment options in patient with PVT.

/pdf/treatment-of-prosthetic-valve-thrombosis-current-evidence-4d32bhw3c3.pdf

Treatment of Prosthetic Valve Thrombosis: Current Evidence and Future Directions.

Introduccion y objetivos Este estudio pretende investigar cual es la mejor terapia inicial para los pacientes que sufren una trombosis protesica obstructiva. Metodos Se analizaron los datos historicos de 47 pacientes que en un periodo de 8 anos habian sido diagnosticados de trombosis protesica en 2 hospitales terciarios. Resultados Las protesis afectadas eran mitrales en 34 casos (2 biologicas), aorticas en 12 y doble protesis mitroaortica en uno. En 12 casos la trombosis no producia obstruccion. En los 35 restantes, la obstruccion protesica fue tratada con heparina (n = 2), trombolisis (n = 19) o cirugia (n = 14). Todos los enfermos del grupo de trombolisis sobrevivieron a la hospitalizacion, si bien seis necesitaron ser operados antes del alta por persistencia de un gradiente elevado (n = 5) o anomalias en el desplazamiento de un disco (n = 1). Cinco de los 14 pacientes del grupo de cirugia directa fallecieron, dos antes de que la operacion pudiera llevarse a efecto. En consecuencia, la tasa de mortalidad, examinada bajo el prisma de intencion de tratar, fue muy favorable para la trombolisis (p = 0,008), y ello a pesar de que el indice de gravedad (en una escala de 0 a 4) era superior en este grupo: 3,3 ± 0,6 frente a 2,1 ± 0,9 en los pacientes del grupo de cirugia directa; p Conclusiones La trombolisis, en terminos de mortalidad hospitalaria, constituye una alternativa mejor que la cirugia directa para combatir la obstruccion trombotica protesica. Aun cuando el resultado pueda resultar suboptimo, permite operar al paciente en mejores condiciones clinicas y, por tanto, con un menor riesgo.

Trombosis valvular protésica: ¿cuál es la terapia inicial más apropiada?

Background: Three-dimensional (3D) echocardiography (echo) and transesophageal echo images enable visualization of valvular anatomy from unique orientations with improved spatial relationships not previously seen with two-dimensional (2D) echo. Materials and Methods: Patients who fulfilled the criteria had undergone detailed evaluation of prosthetic valve dysfunction. Prosthetic valve dysfunction patients with stable hemodynamic were included and 3D echo findings were compared with 2D echo. Results: A total of 10 males and 25 females were evaluated in the study. Two females and one male had bioprosthetic, three males and two females had tilting disc valve, while 21 females and six males had bileaflet mechanical valve. 3D echo had shown abnormal motion of leaflets in seven male and 21 female patients compared to 2D echo. Abnormal valvular calcification was demonstrated in a total of 23 patients on 3D echo. Valve sewing-ring integrity and motion were found abnormal in two male and two female patients in 3D echo. Prosthetic valve dehiscence and thrombus were better seen in five and 15 patients, respectively, on 3D echo. On 3D echo, pannus was better seen in one male and two females. 3D echo defined exact site and size of vegetation better than 2D echo in two female patients. Conclusions: Real-time 3D imaging allows clinically useful visualization of prosthetic valve components such as leaflets, rings, and struts of all prosthetic valves, irrespective of position. “En face” view of the valve has proven useful in the assessment of prosthetic valve endocarditis, paravalvular regurgitation, and prosthesis dysfunction. 3D echo imaging plays an important role in device closure.

Evaluation of prosthetic valve dysfunction by three-dimensional echocardiography

Background Diagnosis of a mechanical mitral valve prosthesis thrombosis is currently made with transthoracic Doppler echocardiography and occasionally with fluoroscopy. However, identifying a thrombus on a valve prosthesis may be difficult, especially if the thrombus is nonobstructive. To prospectively define the role of transesophageal echocardiography for identification of nonobstructive thrombi, we studied a series of patients in whom the prosthetic valve was considered to function normally on clinical examination and transthoracic echocardiography. Methods and Results One hundred fourteen consecutive patients with mechanical mitral valve prosthesis were investigated by both transthoracic echocardiography and transesophageal echocardiography. These examinations were performed for recent systemic emboli (15 patients), fever of unknown etiology (11 patients), routine postoperative evaluation (56 patients), and other reasons (32 patients). Based on transthoracic echo diagnosis, all prostheses were conside...

Transesophageal Echocardiography for the Diagnosis and Management of Nonobstructive Thrombosis of Mechanical Mitral Valve Prosthesis

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Transesophageal Echocardiography for the Diagnosis and Management of Nonobstructive Thrombosis of Mechanical Mitral Valve Prosthesis