Assessing prosthetic heart valve function. Value of Doppler echocardiography and patient/prosthetic valve identity and follow-up card

Significance of "Strands" on Mitral Mechanical Prostheses During Late Follow-Up After Surgery

The presence of "strands" on mitral mechanical prostheses (MMP) has been described, although their significance has yet to be established. The aim of this study was to determine the incidence and clinical implications of "strands" on MMP in late follow-up by a retrospective analysis of 320 consecutive patients who had undergone a transesophageal echocardiographic (TEE) examination under standardized conditions 7 +/- 6 years after mitral surgery. Twenty patients (6.25%) with "strands," defined as highly mobile linear echogenic densities, were identified. This group was compared with a control group of 38 patients, matched for age, sex, and interval between surgery and TEE study, selected at random from this population. Patients with MMP dysfunction were excluded. Type of prosthesis, echographic characteristics (left atrial diameter, spontaneous echo contrast, ejection fraction), and anticoagulant status were not found to bear any relationship to the presence of strands. However, the prevalence of previous embolic events was significantly higher in the "strand" group (10/20 [50%]) than in the control group (7/38 [18.4%]) (P < 0.05). The "strand" group also contained more patients with a prior history of mitral prosthesis thrombosis (7/20 [35%] vs 1/30 [2.6%]; P < 0.05). However, long-term follow-up (1-4 years) was uneventful. These results suggest that: (1) in late follow-up, strands are rare in patients with MMP (6%); and (2) strands were related to previous thromboembolic episodes. (ECHOCARDIOGRAPHY, Volume 13, May 1996)

Transesophageal echocardiography for the diagnosis and management of nonobstructive thrombosis of mechanical mitral valve prosthesis

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 considered normal. Yet, in 20 patients transesophageal echocardiography revealed the presence of a 2- to 15-mm-long mobile thrombus localized on the atrial surface of the prosthesis. When compared with the remaining 94 patients with no visible thrombi, there was no significant difference between the two groups in terms of incidence of atrial fibrillation (65% versus 52%), left atrial size (48 +/- 9 versus 51 +/- 13 mm), left ventricular end-diastolic diameter (49 +/- 10 versus 51 +/- 13 mm) and fractional shortening (28 +/- 9% versus 31 +/- 10%), presence of spontaneous contrast to the left atrium (40% versus 41%), transprosthetic mean pressure gradient (4.0 +/- 1.4 versus 3.9 +/- 1.5 mm Hg), or the type of prosthesis used. After we discovered a nonobstructive thrombosis, patients were treated with heparin (n = 9) or oral anticoagulation (n = 11). The presence of a localized thrombus was confirmed in 3 patients who were operated on. In the present study, evolution appeared to depend on thrombus size: of 14 patients exhibiting a small (< 5 mm) thrombus, 10 had an uneventful course, whereas 5 of 6 patients with a large (> or = 5 mm) thrombus developed complications or died.

CONCLUSIONS

Transesophageal echocardiography appears to be a reliable method to diagnose thrombi on a mechanical mitral valve prosthesis, even when transthoracic Doppler echocardiographic parameters appear to be normal. Transesophageal echo assessment of thrombus size may be helpful in deciding whether a patient with mitral prosthesis should be treated by anticoagulation, thrombolysis, or valve rereplacement.