Recurrent thrombosis of prosthetic mitral valve in idiopathic hypereosinophilic syndrome

A 41-year old man, with idiopathic hypereosinophilic syndrome, had severe mitral regurgitation. He had two subsequent mechanical mitral valve thromboses in the setting of rising eosinophilia. A Carpentier-Edwards bioprosthesis was used for the third valve replacement. Some features of myeloproliferative disease, including chromosome 10 abnormality, were identified. A normal eosinophil count and disappearance of the chromosomal abnormality were obtained with interferon, hydroxyurea and prednisone therapy. At 30 months postoperatively, the patient had a normal lifestyle.     

Obstructive prosthetic mitral valve thrombosis in idiopathic hypereosinophilic syndrome: a case report and review of the literature

Idiopathic hypereosinophilic syndrome (HES) is an uncommon condition characterized by an unexplained elevation of absolute eosinophil count (AEC) to > or = 1.5 x 10(9)/l for at least six months, and is frequently associated with eosinophil-mediated end organ damage. Idiopathic HES, as with secondary HES and primary hypereosinophilic clonal hematopoietic disorders, has a high incidence of myocardial, pulmonary, neurological and other organ injury. Myocardial fibroelastosis and valvular lesions are common, and successful treatment with valve replacement or resection of fibrotic myocardium has been reported. The case is described of a patient with idiopathic HES and multi-organ complications including severe mitral valve disease, in whom a functionally obstructive thrombosis of a newly inserted prosthetic mitral valve occurred despite adequate anticoagulation, when the AEC was profoundly elevated. Recurrent thrombosis has not occurred over a substantial period following AEC reduction with corticosteroids, and subsequent maintenance at normal levels.     

Tenecteplase in prosthetic mitral valve thrombosis

In the few reported cases of prosthetic mitral valve thrombosis, where surgical intervention was considered as high risk, fibrinolytic therapy had proved life saving. The authors present clinical, laboratory, and imaging data from such a patient, with prosthetic mitral valve thrombosis and its successful management with tenecteplase. The use of tenecteplase as a viable fibrinolytic agent for the first time was justified, due to the lack of immunogenicity concerns compared to streptokinase.     

Reoperative minimally invasive mitral valve replacement for bovine pericardial valve thrombosis secondary to idiopathic hypereosinophilic syndrome

Bioprosthetic mitral valves rarely obstruct. We present an older woman who presented with rapidly progressive dyspnea 4 years after bovine mitral replacement. Investigations demonstrated severe mitral stenosis with large, obstructive masses within the previous mitral prosthesis and an elevated eosinophil count. She underwent urgent reoperative mitral replacement and tricuspid valve repair through a 4-cm right minithoracotomy under hypothermic, fibrillatory arrest. Pathologic analysis revealed eosinophilic infiltrates in the obstructive masses and normal endomyocardial biopsies. She made an uneventful recovery and was discharged on steroids to suppress the eosinophilia. Repeat echocardiography demonstrated a well-functioning porcine valve without leaflet restriction or obstruction.     

Acute thrombosis of a prosthetic mitral valve.

We report the case of a patient who was transferred to our hospital with acute thrombosis of a prosthetic mitral valve. Her admission INR was subtherapeutic. The transoesophageal echocardiographic images are presented. The patient underwent urgent reoperation and made a good recovery.     

Successful thrombolysis of prosthetic mitral valve thrombosis in early pregnancy

Prosthetic valve thrombosis occurring during pregnancy is a life-threatening complication. Surgical treatment requires clot removal or valve replacement under cardiopulmonary bypass, and carries a high mortality. We report successful thrombolytic therapy with streptokinase for prosthetic valve thrombosis in a pregnant, 28-year-old woman. The patient, who had undergone mitral valve replacement (St. Jude Medical prosthesis) two years previously for restenosis after closed mitral valvotomy, was successfully thrombolyzed during the first trimester (6-8 weeks) for prosthetic valve thrombosis, and without any complication. The patient delivered a normal healthy child at nine months' gestation. Although thrombolysis in pregnancy has been reported previously, this is the first case in which it was performed during the first trimester for prosthetic valve thrombosis.     

Ross procedure after prosthetic valve thrombosis in a patient with antiphospholipid syndrome and recurrent bleeding

The Ross procedure allows replacement of a diseased aortic valve with pulmonary root autograft, possibly avoiding the highly thrombotic mechanical valves and immunologic deterioration of tissue valves in antiphospholipid syndrome (APS). Here, we present the use of the Ross procedure in a 42-year-old woman with mild intellectual disability, APS, and a complex anticoagulation history after she presented with thrombosis of her mechanical On-X aortic valve previously implanted for non-bacterial thrombotic endocarditis.     

Streptokinase therapy in a five-year-old child with prosthetic mitral valve thrombosis

Intravenous streptokinase therapy for prosthetic valve thrombosis in a 5-year-old child is reported for its rarity. The therapy is safe and effective and as in adults, should be considered the first line of treatment for prosthetic valve thrombosis in children.     

Tenecteplase versus streptokinase thrombolytic therapy in patients with mitral prosthetic valve thrombosis

ObjectiveProsthetic valve thrombosis (PVT) is a dreadful complication of mechanical prosthetic valves. Thrombolytic therapy (TT) for PVT is an alternative to surgery and currently making a leading role. This study compares TT with tenecteplase (TNK) and streptokinase (SK) head to head in patients with mitral PVT.MethodsIn this single center, observational study, patients with mitral PVT diagnosed by clinical data, transthoracic echocardiography, transesophageal echocardiography, and fluoroscopy were included. After excluding patients with contraindications for thrombolysis, they were randomly assigned to receive either SK or TNK regimen. Patients were monitored for success or failure of TT and for any complications.ResultsAmong 52 episodes (47 patients with 5 recurrences) of mechanical mitral PVT, 40 patients were thrombolyzed with SK and 12 patients were thrombolyzed with TNK. Baseline characteristics including demographic profile, clinical and echocardiographic features, and valve types were not statistically significant between the groups. Complete success rate was 77.5% in SK group and 75% in TNK group (p = 0.88). Partial success rate, failure rate, and major complications were not statistically significant between the two groups. Within 12 h of therapy, TNK showed complete success in 33.3% of patients compared to 15% in SK group (p-value <0.02). Minor bleeding was more common in TNK group.ConclusionSlow infusion of TNK is equally efficacious but more effective than SK in the management of mitral mechanical PVT. 75% to 77.5% of PVT patients completely recovered from TT and it should be the first line therapy where the immediate surgical options were remote.     

Management of prosthetic valve thrombosis

Prosthetic valve thrombosis (PVT) is a life-threatening disease, the treatment strategies for which remain controversial. Transesophageal echocardiography (TEE) is the diagnostic technique of choice. Prosthetic valve obstruction is defined as limited leaflet motion; obstructive and non-obstructive PVT are separated by abnormal or normal leaflet motion. TEE is limited in differentiating thrombus from pannus ('tissue ingrowth'), and sterile thrombi from infected vegetations. Clinical aspects are helpful. The estimated incidence of PVT is 2-4% per year based on autopsy and surgical findings. The true incidence should be higher, as TEE reveals almost as many obstructive as non-obstructive PVT, of which 50% are asymptomatic. The prevalence of asymptomatic non-obstructive PVT in the early postoperative period may reach 10%. Three therapeutic approaches are available for PVT. Surgical mortality may reach 69%, depending on NYHA class and need for emergency surgery. Thrombolysis represents an alternative to surgery, with 84% success and low complication rates (stroke 9%, mortality 5%). In non-obstructive PVT patients in NYHA class I or II, thrombolysis success was higher (92%), without severe complications. No other clinical predictor of success could be confirmed. Besides classical contraindications there are no absolute contraindications (large thrombi, pregnancy, early postoperative period) for thrombolysis. Long-term streptokinase protocols have been used with regular TEE monitoring. Heparin may be an initial treatment for non-obstructive PVT, but thrombolysis is superior in this subset. If thrombi are > 5 mm in size, heparin therapy is unsuccessful and unsafe. TEE monitoring is mandatory during heparin treatment, as thrombi may increase in size and become obstructive. Thrombolysis is recommended as first-line treatment if there are no contraindications. Heparin may be used initially for small non-obstructive thrombi, particularly if thrombolysis is contraindicated. Surgery should be reserved for patients in whom thrombolysis is either contraindicated or has been ineffective, independent of NYHA class.     

An unusual presentation of hemolytic anemia in a patient with prosthetic mitral valve

Although rare, periprosthetic valvular regurgitation can cause hemolytic anemia. We present the case of a 63-year-old man who had an unusual presentation of hemolytic anemia due to periprosthetic mitral valve regurgitation (PMVR) in the presence of cold agglutinins. Due to high surgical risk, PMVR was percutaneously closed with three Amplatzer devices under the guidance of three-dimensional transesophageal echocardiography.     

Architecture of a native mitral valve thrombus in a patient with hypereosinophilic syndrome

A 27-year-old male with a six-year history of hypereosinophilic syndrome (HES) presented with a native mitral valve thrombus, despite therapeutic oral anticoagulation. The thrombus was removed, the mitral valve replaced, and subsequent oral anticoagulation maintained at a higher level (INR 3.5). The patient developed two recurrences of mitral valve thrombosis requiring urgent reoperations, and died shortly after the second intervention. A scanning electron microscopy analysis of the native mitral valve thrombus removed during the first cardiac surgery revealed tightly packed thin fibrin strands forming fuzzy irregular structures, with areas of an almost solid fibrin clot. The fibrin networks indicated a heightened thrombin generation, and may account for a diminished susceptibility to intrinsic fibrinolysis. In conclusion, the unfavorably altered compact structure of the fibrin-rich thrombus, which formed despite adequate anticoagulation, might in part explain the recurrent valvular thrombosis. It may also represent a novel prothrombotic mechanism that operates in HES.     

Assessment of mitral prosthetic valve thrombosis by live three-dimensional echocardiography: comparison with transesophageal echocardiography

We report the feasibility of transthoracic live three-dimensional echocardiography in the diagnosis of a thrombus attached to the mitral bioprosthetic valve.     

Coronary arteriography and atrial thrombosis in mitral valve disease

The arteriographic findings of neovascularity and fistula formation from the coronary arteries to the left atrium have occasionally been reported in association with atrial thrombosis in patients with mitral valve disease. To establish the diagnostic value of these findings, the preoperative coronary angiograms of 507 patients who underwent open mitral valve surgery were reviewed. Atrial thrombosis was present in 76 patients (14.9 percent). In the 30 patients with angiographic neovascularity and fistula formation, the thrombi were always observed to arise from the circumflex coronary artery. None of these 30 patients had atherosclerotic coronary lesions. In 25 of these patients an atrial thrombus was found at operation.These coronary arteriographic findings, in this selected group of patients, had a predictive accuracy of 83.3 percent, a specificity of 98.8 percent and a sensitivity of 32.8 percent for the diagnosis of the presence of thrombus in the left atrium. No relation was found between these signs and the size and histologic age of the thrombl examined.     

The use of transesophageal echocardiography guidance of thrombolytic therapy in prosthetic mitral valve thrombosis

BACKGROUND AND AIM OF THE STUDY: The aim of the study was to assess the use of transesophageal echocardiography (TEE) to guide thrombolytic therapy in prosthetic mitral valve thrombosis. METHODS: Twenty-nine consecutive cases of prosthetic mitral valve thrombus diagnosed between January 1995 and May 1998 were managed according to data obtained by TEE. Three patients with pedunculated thrombus and five in NYHA functional classes I-II were referred for surgery. Patients who refused surgery or who were in NYHA classes III-IV and had unpedunculated thrombus were selected for thrombolytic therapy. Twenty-one patients (seven males, 14 females; mean age 47 +/- 8 years) received streptokinase for thrombolysis. RESULTS: The mean period from valve replacement surgery was 36 +/- 23 months, and mean time from onset of symptoms 9.2 +/- 14.3 days. Anticoagulant use was inadequate in 18 (86%) patients. Fourteen cases (66%) were NYHA class IV, four (19%) in class III, and three (15%) in class II. Ten patients (48%) were in atrial fibrillation. During the first 24 h of thrombolytic therapy, mean mitral valve peak and mean gradients fell from 25.6 +/- 4 and 13.8 +/- 2.5 mmHg to 11.7 +/- 5.3 and 7.1 +/- 3.1 mmHg respectively (p <0.0001). Five cases with inadequate response to thrombolysis were treated for an additional 24 h. The mitral valve area increased from 1.0 +/- 0.1 cm2 to 2.3 +/- 0.7 cm2 after the first month (p <0.0001). Complete early success in thrombolysis was achieved in 17 (81%) cases, three cases (14%) had partial success, and one case (5%) was referred for surgery on the third day because of failed thrombolysis. Two minor skin bleedings (9%) not requiring transfusion were attributed to thrombolytic therapy. One case (5%) of successful thrombolysis had a non-fatal stroke after therapy and one (5%) was referred for surgery for recurrent prosthetic mitral valve thrombosis at six months' follow up. None of the surgically treated patients died. CONCLUSION: Guidance of thrombolysis by TEE may reduce, but not eliminate, the risk of thromboembolic complications. Response to thrombolysis became apparent within 24 h, but extending treatment beyond this time provided no additional short-term benefit.     

Percutaneous management of prosthetic valve thrombosis

Background

Thrombosis of a prosthetic valve is a serious complication in patients with prosthetic heart valves. Thrombolysis is the initial choice of treatment. Patients who do not respond to thrombolysis are subjected to surgery which carries a high risk. We report a case series of 5 patients with prosthetic mitral valve thrombosis who did not respond to thrombolysis and were subjected to percutaneous manipulation of the prosthetic valves successfully and improved.

Methods

Five patients who were diagnosed to have prosthetic mitral valve thrombosis and failed to respond to a minimum of 36 h of thrombolysis (persistent symptoms with increased gradients, abnormal findings on fluoroscopy),were subjected to percutaneous treatment after receiving proper consent. None of them had a visible thrombus on transthoracic echocardiogram. All patients underwent transseptal puncture following which a 6F JR4 guiding catheter was passed into the left atrium. The valve leaflets were repeatedly hit gently under fluoroscopic guidance till they regained their normal mobility.

Results

Mean age was 38.8 years. Average peak and mean gradients prior to the procedure were 38 and 25 and after the procedure were 12 and 6 mm of Hg respectively. All patients had successful recovery of valve motion on fluoroscopy with normalization of gradients and complete resolution of symptoms. None of the patients had any focal neurological deficits, embolic manifestations or bleeding complications.

Conclusions

Percutaneous manipulation of prosthetic valves in selected patients with prosthetic valve thrombosis who do not respond to thrombolytic therapy is feasible and can be used as an alternative to surgery.