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Serban A, Gavan D, Pepine D, Dadarlat A, Tomoaia R, Mot S, Achim A. Mechanical valve thrombosis: Current management and differences between guidelines. Trends Cardiovasc Med 2024; 34:351-359. [PMID: 37499958 DOI: 10.1016/j.tcm.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/05/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023]
Abstract
All foreign bodies inserted in the circulatory system are thrombogenic and require temporary or lifelong antithrombotic therapies to prevent thrombosis. The adequate level of anticoagulation during the first few months determines the long-term durability, particularly for mechanical prostheses, and also for biological valves. Suboptimal anticoagulation is the most frequent source of mechanical valve thrombosis (MVT). The patient's clinical presentation decides how mechanical prosthetic valve obstruction is managed. If the mechanical valve thrombosis is obstructive and the patient is in a critical condition with hemodynamic instability, an immediate surgical intervention should be performed. The thrombolytic treatment is an option for left mechanical valve thrombosis in patients who have high surgical risk and no contraindications and also for right heart valve thrombosis. In non-obstructive thrombosis on the mechanical valve, patients can be asymptomatic, requiring optimization of the anticoagulant treatment. Both obstructive and non-obstructive thrombus formed on the mechanical prosthesis can result in embolic events. If the thrombus persists following anticoagulant treatment, the recommended options include thrombolytic treatment or redo surgery. Pannus can also cause obstruction of the prosthesis for which surgical treatment is the only option. While these clinical scenarios may initially appear to have straightforward solutions in terms of surgery, thrombolysis, or effective anticoagulation, real-world clinical experience often proves more complex. For instance, a patient with some usual comorbidities and non-obstructive mechanical valve thrombosis, experiencing symptoms solely by repeated systemic embolizations, might undergo all three therapeutic options due to the unpredictable nature of MVT. Therefore, treatment indications can intersect both on the time axis and depending on the patient's clinical status and the expertise of the center where he is hospitalized. Moreover, the European and American guidelines show subtle but important differences. The aim of this review was to compare these differences, comment on recent studies and evidence gaps, propose a more pragmatic algorithm combining all current recommendations, and highlight important research directions for this disease that has dominated the cardiovascular landscape for more than five decades, but for which there have been no significant recent changes in management.
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Affiliation(s)
- Adela Serban
- Department of Cardiology, Heart Institute Niculae Stăncioiu, Cluj-Napoca, Romania; 5th Department of Internal Medicine, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Dana Gavan
- Department of Cardiology, Heart Institute Niculae Stăncioiu, Cluj-Napoca, Romania
| | - Diana Pepine
- Department of Cardiology, Heart Institute Niculae Stăncioiu, Cluj-Napoca, Romania
| | - Alexandra Dadarlat
- Department of Cardiology, Heart Institute Niculae Stăncioiu, Cluj-Napoca, Romania; 5th Department of Internal Medicine, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Raluca Tomoaia
- 5th Department of Internal Medicine, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania; Department of Cardiology, Clinical Rehabilitation Hospital, Cluj-Napoca, Romania
| | - Stefan Mot
- Department of Cardiology, Heart Institute Niculae Stăncioiu, Cluj-Napoca, Romania; 5th Department of Internal Medicine, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Alexandru Achim
- Department of Cardiology, Heart Institute Niculae Stăncioiu, Cluj-Napoca, Romania; Department of Cardiology, Medizinische Universitätsklinik, Kantonsspital Baselland, Liestal, Switzerland.
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Ebrahimi P, Sattartabar B, Taheri H, Soltani P, Bahiraie P, Mousavinezhad SM, Gooshvar M, Kampaktsis PN, Arsanjani R, Sahebjam M, Hosseini K, Siegel RJ. Mechanical prosthetic valve thrombosis: A literature review of treatment strategies. Curr Probl Cardiol 2024; 49:102628. [PMID: 38729276 DOI: 10.1016/j.cpcardiol.2024.102628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/06/2024] [Indexed: 05/12/2024]
Abstract
Mechanical prosthetic valve thrombosis (MPVT) is a common complication of valvular implantations. This study compared the efficacy and safety of different treatments for MPVT. A systematic search of electronic databases identified studies evaluating surgical, anticoagulant, and thrombolytic therapies. Although several studies of different types have been conducted to evaluate the efficacy of these treatment strategies the lack of randomized controlled trials has resulted in the inability to make a definitive conclusion about the pros and cons of these treatments. Recent treatments, such as slow and ultraslow infusion of thrombolytics, showed comparable efficacy and lower complication rates than traditional methods. Inadequate anticoagulant use is a major risk factor for MPVT, highlighting the importance of prevention. Treatment selection should be individualized based on patient factors and available expertise. Overall, slow and ultraslow infusion of thrombolytics may be a promising treatment option for MPVT.
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Affiliation(s)
- Pouya Ebrahimi
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Babak Sattartabar
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Homa Taheri
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Parnian Soltani
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Pegah Bahiraie
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Mehrdad Gooshvar
- School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Mohammad Sahebjam
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kaveh Hosseini
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
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McGuire C, Yang M, Papolos A, Rogers T, Kenigsberg B. Dual mechanical valve thrombosis resolution through thrombolytics: a case series. Eur Heart J Case Rep 2023; 7:ytad399. [PMID: 37671250 PMCID: PMC10476460 DOI: 10.1093/ehjcr/ytad399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/01/2023] [Accepted: 08/15/2023] [Indexed: 09/07/2023]
Abstract
Background Prosthetic valve thrombosis (PVT) is a severe complication of mechanical valve replacement. Simultaneous thrombosis of multiple prosthetic valves is rare and is associated with worse outcomes. Treatment options include anticoagulation, thrombolysis, and redo operative valve replacement, with rare reports of adjunctive balloon valvuloplasty. There is limited evidence to guide therapeutic selection, specifically dosing, timing, and duration of thrombolysis. The following case series highlights the importance of successful thrombolytic management in dual PVT with high bleeding risk defined as a coagulopathy with an elevated international normalized ratio greater than 3 and New York Heart Association (NYHA) Class III and IV heart failure. Case summary We describe two patients with concomitant aortic and mitral PVT. Both patients presented in NYHA Class III and IV heart failure with different challenges to surgical treatments including high bleeding risk from coagulopathy and history of multiple prior sternotomies. After multi-disciplinary discussions, both patients underwent a combination of low-dose, slow, or ultra-slow infusion of tissue plasminogen activator, with a resolution of their dual PVT seen on cine-fluoroscopy imaging as freely moving mechanical leaflets and improvement of heart failure symptoms back to baseline NYHA Class II or lower. Discussion Prosthetic valve thrombosis is a complex medical condition requiring a multi-disciplinary team to evaluate the best course of treatment. A trial of pharmacologic thrombolysis is often the first attempted treatment for obstructive PVT, although surgery is recommended for patients with NYHA IV symptoms, or with contraindications to thrombolysis, including high bleeding risk. However, in patients with high bleeding risk and NYHA Class III and IV heart failure, especially with surgical contraindications, low-dose thrombolytics, with slow or ultra-slow infusions, may still be safe and effective treatment strategies for multi-valve PVT. Further research is needed to guide thrombolysis in multi-valve PVT.
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Affiliation(s)
- Colin McGuire
- Department of Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Michael Yang
- Division of Cardiology, Medstar Washington Hospital Center, 110 Irving St., NW, Washington, DC, USA
| | - Alexander Papolos
- Division of Cardiology, Medstar Washington Hospital Center, 110 Irving St., NW, Washington, DC, USA
- Department of Critical Care Medicine, Medstar Washington Hospital Center, 110 Irving St., NW, Washington, DC, USA
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
- Cardiovascular Intervention Program, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Benjamin Kenigsberg
- Division of Cardiology, Medstar Washington Hospital Center, 110 Irving St., NW, Washington, DC, USA
- Department of Critical Care Medicine, Medstar Washington Hospital Center, 110 Irving St., NW, Washington, DC, USA
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Soria Jiménez CE, Papolos AI, Kenigsberg BB, Ben-Dor I, Satler LF, Waksman R, Cohen JE, Rogers T. Management of Mechanical Prosthetic Heart Valve Thrombosis: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:2115-2127. [PMID: 37225366 DOI: 10.1016/j.jacc.2023.03.412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 05/26/2023]
Abstract
Mechanical prosthetic heart valves, though more durable than bioprostheses, are more thrombogenic and require lifelong anticoagulation. Mechanical valve dysfunction can be caused by 4 main phenomena: 1) thrombosis; 2) fibrotic pannus ingrowth; 3) degeneration; and 4) endocarditis. Mechanical valve thrombosis (MVT) is a known complication with clinical presentation ranging from incidental imaging finding to cardiogenic shock. Thus, a high index of suspicion and expedited evaluation are essential. Multimodality imaging, including echocardiography, cine-fluoroscopy, and computed tomography, is commonly used to diagnose MVT and follow treatment response. Although surgery is oftentimes required for obstructive MVT, other guideline-recommended therapies include parenteral anticoagulation and thrombolysis. Transcatheter manipulation of stuck mechanical valve leaflet is another treatment option for those with contraindications to thrombolytic therapy or prohibitive surgical risk or as a bridge to surgery. The optimal strategy depends on degree of valve obstruction and the patient's comorbidities and hemodynamic status on presentation.
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Affiliation(s)
- César E Soria Jiménez
- Division of Cardiology, MedStar Washington/Georgetown University Hospital Center, Washington, DC, USA
| | - Alexander I Papolos
- Division of Cardiology, MedStar Washington/Georgetown University Hospital Center, Washington, DC, USA; Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Benjamin B Kenigsberg
- Division of Cardiology, MedStar Washington/Georgetown University Hospital Center, Washington, DC, USA; Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jeffrey E Cohen
- Department of Cardiac Surgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
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Jain A, Marimuthu V, Alur N. Mechanical prosthetic valve thrombosis after ChAdOx1-nCoV-19 vaccination: A case report. IHJ CARDIOVASCULAR CASE REPORTS (CVCR) 2022. [PMCID: PMC9536874 DOI: 10.1016/j.ihjccr.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The ChAdOx1 nCoV-19 adenoviral vector-based vaccine was the first to be approved against COVID-19 in India. Vaccine induced thrombotic thrombocytopenia (VITT) is a rare but serious adverse effect of the ChAdOx1 nCoV-19 vaccine, causing widespread thrombosis and thrombocytopenia. A 22-year-old patient, who had undergone mechanical mitral valve replacement, presented to us one week after administration of 1st dose of the ChAdOx1 nCoV-19 Coronavirus vaccine with acute prosthetic heart valve thrombosis (PVT). Laboratory investigations revealed thrombocytopenia and high D-Dimer levels, suggestive of probable VITT. In this report, we highlight the importance of identification of VITT as a cause of PVT and discuss management options.
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Farzaneh K, Mortazavi SH, Oraii A, Abbasi K, Salehi Omran A, Ahmadi Tafti SH, Bozorgi A, Kazemi Saeed A, Salarifar M, Sadeghian S. Safety of thrombolytic therapy in patients with prosthetic heart valve thrombosis who have high international normalized ratio levels. J Card Surg 2020; 35:2522-2528. [DOI: 10.1111/jocs.14777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Khadijeh Farzaneh
- Department of Cardiology, Tehran Heart Center Tehran University of Medical Sciences Tehran Iran
| | | | - Alireza Oraii
- Tehran Heart Center Tehran University of Medical Sciences Tehran Iran
| | - Kyomars Abbasi
- Department of Cardiac Surgery, Tehran Heart Center Tehran University of Medical Sciences Tehran Iran
| | - Abbas Salehi Omran
- Department of Cardiac Surgery, Tehran Heart Center Tehran University of Medical Sciences Tehran Iran
| | | | - Ali Bozorgi
- Department of Cardiology, Tehran Heart Center Tehran University of Medical Sciences Tehran Iran
| | - Ali Kazemi Saeed
- Department of Cardiology, Tehran Heart Center Tehran University of Medical Sciences Tehran Iran
| | - Mojtaba Salarifar
- Department of Cardiology, Tehran Heart Center Tehran University of Medical Sciences Tehran Iran
| | - Saeed Sadeghian
- Department of Cardiology, Tehran Heart Center Tehran University of Medical Sciences Tehran Iran
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Gündüz S, Kalçık M, Gürsoy MO, Güner A, Özkan M. Diagnosis, treatment & management of prosthetic valve thrombosis: the key considerations. Expert Rev Med Devices 2020; 17:209-221. [DOI: 10.1080/17434440.2020.1733972] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Sabahattin Gündüz
- Department of Cardiology, VM Medikal Park Pendik Hospital, Istanbul, Turkey
| | - Macit Kalçık
- Department of Cardiology, Faculty of Medicine, Hitit University, Corum, Turkey
| | - Mustafa Ozan Gürsoy
- Department of Cardiology, Izmir Katip Çelebi University Atatürk Training and Research Hospital, Izmir, Turkey
| | - Ahmet Güner
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training & Research Hospital, Istanbul, Turkey
| | - Mehmet Özkan
- Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
- School of Health Sciences, Ardahan University, Ardahan, Turkey
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