Two Cases of Acute Bioprosthetic Mitral Valve Thrombosis Immediately After Mitral Valve Replacement
2014; Lippincott Williams & Wilkins; Volume: 129; Issue: 6 Linguagem: Inglês
10.1161/circulationaha.113.005583
ISSN1524-4539
AutoresNobuyuki Kagiyama, Hiroyuki Okura, Shintaro Nezuo, Takahiro Kawamoto, Takashi Murakami, Yuji Hashimoto, Kazuo Tanemoto, Kiyoshi Yoshida,
Tópico(s)Cardiac Structural Anomalies and Repair
ResumoHomeCirculationVol. 129, No. 6Two Cases of Acute Bioprosthetic Mitral Valve Thrombosis Immediately After Mitral Valve Replacement Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBTwo Cases of Acute Bioprosthetic Mitral Valve Thrombosis Immediately After Mitral Valve Replacement Nobuyuki Kagiyama, MD, Hiroyuki Okura, MD, PhD, Shintaro Nezuo, MD, Takahiro Kawamoto, MD, PhD, Takashi Murakami, MD, PhD, Yuji Hashimoto, MD, PhD, Kazuo Tanemoto, MD, PhD and Kiyoshi Yoshida, MD, PhD Nobuyuki KagiyamaNobuyuki Kagiyama From the Division of Cardiology (N.K., H.O., S.N., T.K., K.Y.) and Department of Cardiovascular Surgery (K.T.), Kawasaki Medical School, Kurashiki, Japan; and Departments of Cardiovascular Surgery (T.M.) and Cardiology (Y.H.), Kameda Medical Center, Kamogawa, Japan. , Hiroyuki OkuraHiroyuki Okura From the Division of Cardiology (N.K., H.O., S.N., T.K., K.Y.) and Department of Cardiovascular Surgery (K.T.), Kawasaki Medical School, Kurashiki, Japan; and Departments of Cardiovascular Surgery (T.M.) and Cardiology (Y.H.), Kameda Medical Center, Kamogawa, Japan. , Shintaro NezuoShintaro Nezuo From the Division of Cardiology (N.K., H.O., S.N., T.K., K.Y.) and Department of Cardiovascular Surgery (K.T.), Kawasaki Medical School, Kurashiki, Japan; and Departments of Cardiovascular Surgery (T.M.) and Cardiology (Y.H.), Kameda Medical Center, Kamogawa, Japan. , Takahiro KawamotoTakahiro Kawamoto From the Division of Cardiology (N.K., H.O., S.N., T.K., K.Y.) and Department of Cardiovascular Surgery (K.T.), Kawasaki Medical School, Kurashiki, Japan; and Departments of Cardiovascular Surgery (T.M.) and Cardiology (Y.H.), Kameda Medical Center, Kamogawa, Japan. , Takashi MurakamiTakashi Murakami From the Division of Cardiology (N.K., H.O., S.N., T.K., K.Y.) and Department of Cardiovascular Surgery (K.T.), Kawasaki Medical School, Kurashiki, Japan; and Departments of Cardiovascular Surgery (T.M.) and Cardiology (Y.H.), Kameda Medical Center, Kamogawa, Japan. , Yuji HashimotoYuji Hashimoto From the Division of Cardiology (N.K., H.O., S.N., T.K., K.Y.) and Department of Cardiovascular Surgery (K.T.), Kawasaki Medical School, Kurashiki, Japan; and Departments of Cardiovascular Surgery (T.M.) and Cardiology (Y.H.), Kameda Medical Center, Kamogawa, Japan. , Kazuo TanemotoKazuo Tanemoto From the Division of Cardiology (N.K., H.O., S.N., T.K., K.Y.) and Department of Cardiovascular Surgery (K.T.), Kawasaki Medical School, Kurashiki, Japan; and Departments of Cardiovascular Surgery (T.M.) and Cardiology (Y.H.), Kameda Medical Center, Kamogawa, Japan. and Kiyoshi YoshidaKiyoshi Yoshida From the Division of Cardiology (N.K., H.O., S.N., T.K., K.Y.) and Department of Cardiovascular Surgery (K.T.), Kawasaki Medical School, Kurashiki, Japan; and Departments of Cardiovascular Surgery (T.M.) and Cardiology (Y.H.), Kameda Medical Center, Kamogawa, Japan. Originally published11 Feb 2014https://doi.org/10.1161/CIRCULATIONAHA.113.005583Circulation. 2014;129:e328–e330IntroductionProsthetic valve thrombosis (PVT) is a rare complication, and most of PVT occurs in patients with mechanical valves. We present 2 extremely rare cases of acute bioprosthetic mitral valve thrombosis immediately after mitral valve replacement under veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and anticoagulant therapy.In Case 1, a 75-year-old woman underwent aortic valve replacement and mitral valve replacement with 23- and 29-mm bioprosthetic valves, respectively. On postoperative day 2, VA-ECMO was started because of hemodynamic compromise. At the initiation of VA-ECMO, transthoracic echocardiography indicated normal bioprosthesis function (Figure 1; see Movie I in the online-only Data Supplement). On postoperative day 9, transesophageal echocardiography revealed severely stenotic bioprosthetic mitral valve, but the bioprosthetic aortic valve was normal (Figure 2; see Movies II and III in the online-only Data Supplement). Emergent percutaneous mitral valvuloplasty was performed, resulting in partial improvement of hemodynamic state. On postoperative day 17, re-mitral valve replacement was performed. The left atrial side of the retrieved bioprosthetic valve leaflet was covered with thrombus, resulting in leaflet fusion (Figure 3).Download figureDownload PowerPointFigure 1. Transthoracic echocardiographic image at the initiation of veno-arterial extracorporeal membrane oxygen in case 1. Laminar flow through the bioprosthetic mitral valve and continuous-wave Doppler tracing indicated normal valve function. LA indicates left atrium; LV, left ventricle; MPG, mean pressure gradient; PV, peak velocity; PHT, pressure-half time; RA, right atrium; and RV, right ventricle.Download figureDownload PowerPointFigure 2. Transesophageal echocardiography (TEE) images of the stenotic bioprosthetic valve in case 1. TEE showed severely reduced opening of the bioprosthetic mitral valve. The leaflet tips were tightly fused, whereas leaflet mid and base portions had some mobility (A and B). Transmitral continuous-wave Doppler tracing showed elevated mean pressure gradient (13.9 mm Hg; C). LA indicates left atrium; LV, left ventricle; MPG, mean pressure gradient; PV, peak velocity; PHT, pressure-half time; RA, right atrium; and RV, right ventricle.Download figureDownload PowerPointFigure 3. Retrieved prosthetic mitral valve in Case 1. Leaflets of the retrieved bioprosthetic valve were tightly fused with thrombus (A). Histological section revealed that left atrial side of the leaflet was covered with thrombus. Neovascularization was observed within the thrombus (B; magnification ×40; C, ×200). LA indicates left atrium; and LV, left ventricle.In Case 2, a 70-year-old man underwent emergent mitral valve replacement with a 27-mm bioprosthetic valve attributable to acute myocardial infarction with rupture of a papillary muscle. During the procedure, VA-ECMO was started and continued. Two days later, transesophageal echocardiography revealed that the bioprosthetic valve was thickened and its opening was restricted (Figure 4; see Movies IV and V in the online-only Data Supplement). Intravenous infusion of urokinase at a dose of 10 000 U/h was started and continued for 3 days. After thrombolysis, transesophageal echocardiography showed that the thickening of the valve ameliorated and its opening improved (Figure 5; see Movies VI and VII in the online-only Data Supplement). His hemodynamic state improved, and he could be weaned off VA-ECMO.Download figureDownload PowerPointFigure 4. Three-dimensional transesophageal echocardiography (TEE) image and color Doppler image in Case 2. Three-dimensional TEE revealed that 2 of 3 leaflets of the bioprosthetic valve kept closed (A). A color Doppler image during diastole showed convergence flow proximal to the valve orifice and mosaic signal distal to the orifice, indicating severe prosthetic valve stenosis (B).Download figureDownload PowerPointFigure 5. Transesophageal echocardiographic images before and after thrombolysis in case 2. Marked thick mitral prosthetic valve was observed before thrombolysis (A). After thrombolysis, the prosthetic valve became thin and opened more smoothly (C). Transmitral continuous-wave Doppler tracing also showed clear improvement of the prosthetic valve stenosis (B and D). LA indicates left atrium; LV, left ventricle; MPG, mean pressure gradient; PV, peak velocity; and PHT, pressure-half time.In Case 1, histological examination revealed thrombus formation on the bioprosthetic valve. In Case 2, echocardiographic and clinical findings strongly implicated that thrombosis caused prosthetic valve stenosis. In both cases, PVT developed despite the use of intravenous heparin to maintain the ACT above 150 seconds.Risk factors for PVT have been reported as left atrial dilatation, atrial fibrillation, hypercoagulability, and low cardiac output.1 In our cases, low cardiac output was 1 possible cause of PVT. Recently, cases with left ventricular or bioprosthetic valve thrombosis during VA-ECMO were reported.2,3 VA-ECMO is a device that provides circulatory and pulmonary support with draining blood from the inferior vena cava and sending the blood to the femoral artery. Because it increases left ventricular afterload and decreases preload, cardiac output from the native heart is reduced or completely abandoned, and thereby it may increase the risk of thrombosis in the left heart.3 PVT in our cases may also be developed as a result of decreased blood flow through the prosthetic valves. Adequate device adjustment, or keeping low flow of VA-ECMO using intra-aortic balloon pumping or percutaneous left ventricular assist device, would be useful to prevent thrombosis. In a patient with prosthetic valve under VA-ECMO, more aggressive anticoagulant therapy would also reduce the risk of thrombosis.DisclosuresNone.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.113.005583/-/DC1.Correspondence to Nobuyuki Kagiyama, MD, Division of Cardiology, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192, Japan. E-mail [email protected]References1. Tsiouris A, Nemeh H, Borgi J. Early acute thrombosis of bioprosthetic mitral valve presenting with cardiogenic shock.Gen Thorac Cardiovasc Surg. 2013; 61:152–154.CrossrefMedlineGoogle Scholar2. Moubarak G, Weiss N, Leprince P, Luyt CE. Massive intraventricular thrombus complicating extracorporeal membrane oxygenation support.Can J Cardiol. 2008; 24:e1.CrossrefMedlineGoogle Scholar3. Gottfried R, Paluszkiewicz L, Kizner L, Morshuis M, Koertke H, Gummert J. Thrombosis of a bioprosthetic mitral valve under extracorporeal membrane oxygenation: thrombus formation in the left heart.Ann Thorac Surg. 2012; 94:657.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Lee K, Jung Y, Jeong I, Song S, Na K and Oh S (2021) Acute biological mitral valve thrombosis after the left atrial venting in a patient with a venoarterial extracorporeal membrane oxygenator, Journal of Cardiac Surgery, 10.1111/jocs.16122, 37:2, (437-439), Online publication date: 1-Feb-2022. Simpson M, Dershowitz L and George I (2022) Bridge to Sapien: Mechanical Circulatory Support as a Bridge to Transcatheter Mitral Intervention, The Annals of Thoracic Surgery, 10.1016/j.athoracsur.2021.08.030, 113:6, (e425-e428), Online publication date: 1-Jun-2022. Challa A, Latona J, Fraser J, Spanevello M, Scalia G, Burstow D, Platts D, Garg P, Bouzas-Mosquera A, Abdulhak A, Milasinovic D, Simovic S and Ranganathan D (2020) Mitral valve bio-prosthesis and annuloplasty thrombosis during extracorporeal membrane oxygenation: case series, European Heart Journal - Case Reports, 10.1093/ehjcr/ytaa085, 4:3, (1-6), Online publication date: 1-Jun-2020. Melehy A, Sanchez J, Fried J and Takeda K (2020) Prosthetic valve thrombosis during extracorporeal life support for postcardiotomy shock, Interactive CardioVascular and Thoracic Surgery, 10.1093/icvts/ivaa125, 31:4, (573-575), Online publication date: 1-Oct-2020. Dahl A, Gregory S, Ursprung E, Kawabori M, Couper G and Hueneke R (2019) Acute Presentation of Bioprosthetic Mitral Valve Thrombosis in a Patient on Venoarterial Extracorporeal Membranous Oxygenation, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2018.05.007, 33:3, (844-849), Online publication date: 1-Mar-2019. Nakazato T, Hata H, Toda K, Miyagawa S, Yoshikawa Y, Saito S, Domae K, Ueno T, Kuratani T and Sawa Y (2018) Midterm Clinical Outcomes of the St Jude Medical Epic Porcine Bioprosthesis in the Mitral Position, Circulation Journal, 10.1253/circj.CJ-18-0483, 83:1, (110-116), Online publication date: 25-Dec-2018. Nowacka A, Eeckhout E, Tozzi P and Kirsch M (2018) Early stenosis of bioprosthetic mitral valve during venoarterial extracorporeal life support successfully treated using isolated percutaneous balloon valvuloplasty: a case report, European Heart Journal - Case Reports, 10.1093/ehjcr/ytx024, 2:1, Online publication date: 1-Mar-2018. Imada T, Shibata S, Okitsu K and Fujino Y (2017) Unexpected bioprosthetic mitral valve thrombus during left ventricular assist device implantation, JA Clinical Reports, 10.1186/s40981-017-0086-5, 3:1, Online publication date: 1-Dec-2017. Madathil R, Togashi K, VonHomeyer P and Hermsen J (2015) Acute bioprosthetic mitral valve thrombosis, Intensive Care Medicine, 10.1007/s00134-015-4142-1, 42:6, (1073-1074), Online publication date: 1-Jun-2016. February 11, 2014Vol 129, Issue 6 Advertisement Article InformationMetrics © 2014 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.113.005583PMID: 24515960 Originally publishedFebruary 11, 2014 PDF download Advertisement SubjectsCardiovascular Surgery
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