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

• Published in: European journal of cardio-thoracic surgery 2015-04, Vol.47 (4), p.725-732
• Main Authors: Pislaru, Sorin V., Hussain, Imad, Pellikka, Patricia A., Maleszewski, Joseph J., Hanna, Richard D., Schaff, Hartzell V., Connolly, Heidi M.
• Format: Article
• Language: English
• Subjects: Adult; Aged; Anticoagulants - therapeutic use; Bioprosthesis - adverse effects; Female; Heart Valve Prosthesis - adverse effects; Humans; Male; Middle Aged; Retrospective Studies; Thrombosis - diagnosis; Thrombosis - etiology; Thrombosis - therapy; Vitamin K - antagonists & inhibitors
• ISSN: 1010-7940; 1873-734X
• DOI: 10.1093/ejcts/ezu201

OBJECTIVES Bioprosthetic valve thrombosis (BPVT) is a rare but potentially life-threatening complication. Current guidelines favour surgery or thrombolysis as initial treatment. We set forth to characterize timing, diagnostic criteria and treatment strategies in BPVT. METHODS A free-text search tool was used to identify patients diagnosed with BPVT at Mayo Clinic between 1997 and 2013. We compared patients treated initially with vitamin K antagonists (VKA group; N = 15) versus surgery/thrombolysis (non-VKA group; N = 17). RESULTS Peak incidence of BPVT was 13–24 months after implantation in both groups. VKA and surgery/thrombolysis decreased prosthetic mean gradients to a similar extent (VKA group: 13 ± 5 to 6 ± 2 mmHg in mitral position, 9 ± 3 to 5 ± 1 mmHg in tricuspid position and 39 ± 3 to 24 ± 7 mmHg in aortic/pulmonary position; non-VKA group: 16 ± 12 to 5 ± 1 mmHg in mitral, 10 ± 5 to 4 ± 1 mmHg in tricuspid and 57 ± 9 to 18 ± 6 mmHg in aortic position; P = 0.59 for group effect). NYHA class improved in 11 of 15 patients in the VKA group and 10 of 17 patients in the non-VKA group (P = 0.39). There were no deaths, strokes or recognized embolic events; 1 patient in each group experienced gastrointestinal bleeding requiring transfusion. Index transthoracic echocardiogram formally identified BPVT in a minority of patients. CONCLUSIONS 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.