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J Thorac Cardiovasc Surg 1998;115:248-249
© 1998 Mosby, Inc.

BRIEF COMMUNICATIONS

Thrombolysis of thrombosed St. Jude medical prosthetic valves:rethrombosis—a sign of tissue ingrowth

KwaZulu/Natal, South Africa

From the Department of Cardiology, University ofNatal/Wentworth Hospital, Durban, KwaZulu/Natal, South Africa.

Published data were partly presented at Nineteenth Biennial Congressof Southern African Cardiac Society, Cape Town, Nov. 27-30, 1994.

Received for publication July 18, 1997 Accepted for publication August 18, 1997 Address for reprints: M. J. Munclinger, MD, Cardiac Unit,Wentworth Hospital, Private Bag Jacobs, Durban 4026, KwaZulu/Natal, SouthAfrica.

Prosthetic valve thrombosis is one of the most frequent complicationsafter valve replacement surgery. A second surgical procedure with debridement orreplacement of the valve (or both) has been the traditional method ofmanagement, ¹ with systemicthrombolysis lingering as an alternative for more than two decades. ² The mortality with second valvereplacement has been relatively high (20%). ³ With systemic thrombolysis themortality is lower (0% to 10%) ^2,4,5but is associated with embolic complications that are usually without permanentsequelae. Rethrombosis occurs in 20% of patients after successfulthrombolysis. ⁵ A repeatthrombolysis has been advocated for patients with rethrombosis. ⁵

Results of systemic thrombolysis in 10 patients receiving tissueplasminogen activator (TPA) for thrombosis of a left-sided St. Jude Medicalvalve (St. Jude Medical, Inc., St. Paul, Minn.) are presented here with a focuson the mid-term follow-up and the management of rethrombosis.

The clinical data and the follow-up of 10 consecutive patients aresummarized in Table I. The international normalized ratio on admission was within thetherapeutic range in only three of the 10 patients. The diagnosis wasestablished and the treatment was monitored by cinefluoroscopy. TPA wasadministered as a bolus of 10 mg followed by an infusion of 5 mg/hr. When fullvalve mobility was achieved, TPA was stopped and a continuous infusion ofheparin was commenced. At the same time warfarin was introduced, and when thetherapeutic range of anticoagulation was achieved heparin was discontinued.

During follow-up, one patient who had successful thrombolysis died in aperipheral hospital with clinical signs of rethrombosis 2 weeks after discharge.He had not received therapeutic levels of anticoagulants. Three patients werefound to have poor valve mobility, and a second course of TPA was administered.The second thrombolysis resulted in good valve mobility. All three patients witha second course of TPA returned with evidence of valve dysfunction as documentedby limited leaflet mobility. Two of them were subjected to surgery, and evidenceof tissue ingrowth involving the hinge points of the valves was found, similarto that in the patient who was operated on after an unsuccessful first course ofthrombolysis.

Comparative data concerning the choice of thrombolytic agents are notavailable. We believe that the present group of 10 patients treated with TPA isthe largest reported yet for this agent. The comparison of our results withthose of Vitale and coworkers ⁴suggests that the method of administration (a long-term infusion versus anaccelerated administration) is probably not significant. Rethrombosis was moreprevalent in our patients than in those from other reports. ^2,4,5 Of the five patients with arethrombosis and/or unsuccessful thrombolysis, one died in a peripheral hospitalas a result of inadequate anticoagulation and three others were subjected to asecond valve replacement. Evidence of tissue ingrowth in these three patientsraises the question of whether surgical treatment, without a second course ofthrombolytic agents, should be pursued immediately in patients havingrethrombosis or valve dysfunction after a successful thrombolytic treatment. Tothis end, a retrospective blind reassessment of valve mobility in our patientswas conducted and failed to demonstrate differences between patients in whom thetissue ingrowth was an important factor. We believe that tissue ingrowth was thecause of rethrombosis and not a failure of primary thrombolysis.

The results of reoperation and systemic thrombolysis are probablycomparable, ^1-5 although no randomized study hascompared them. Vitale and associates ⁴used thrombolysis in eight patients with a short duration of symptoms and withpreserved movement of a disc or leaflet and found a very good mid-term results.Another group of 20 patients was submitted to an emergency reoperation, andtissue ingrowth was found in 65% of them; that is, another seven patientscould have profited from thrombolysis. ⁴The definition of reliable echocardiographic criteria of the type of thrombosis(i.e., thrombus only or an apposition of thrombus on preexisting tissueingrowth) by transthoracic or transesophageal echocardiography is necessary toallow an appropriate selection of patients for either method.

Systemic thrombolysis is an additive rather than a competitive method forthe treatment of patients with thrombosed left-sided prosthetic valves. Presentresults confirm that tissue ingrowth is a frequent cause of rethrombosis andsuggests that patients with a recurrence of thrombosis should be submitted to asecond operation rather than to a second course of thrombolysis.

Footnotes

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References

1. Kurzrok S, Singh AK, Most AS, Williams DO.Thrombolytic therapy for prosthetic cardiac valve thrombosis. J Am CollCardiol 1987;9:592-8.
   
2. Silber H, Khan SS, Matloff JM, Chaux A,DeRobertis M, Gray R. The St. Jude valve: thrombolysis as the first line oftherapy for cardiac valve thrombosis. Circulation 1993:87:30-7.
   
3. Deviri E, Sareli P, Wisenbaugh T, Cronje SL.Obstruction of mechanical heart valve prosthesis: clinical aspects and surgicalmanagement. J Am Coll Cardiol 1991;17:646-50.[Abstract]
   
4. Vitale N, Renzulli A, Cerasuolo F, Caruso A,Festa M, de Luca L, et al. Prosthetic valve obstruction: thrombolysis versusoperation. Ann Thorac Surg 1994;57:365-70.[Abstract]
   
5. Reddy NK, Padmanabhan TNC, Singh S, Kumar DN,Raju PR, Satyanarayana PV, et al. Thrombolysis in left-sided prosthetic valveocclusion: immediate and follow-up results. Ann Thorac Surg 1994;58:462-71.[Abstract]
   

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