Portal de Periódicos da CAPES

Huge Prosthetic Mitral Valve Thrombosis in a Pregnant Woman

2009; Lippincott Williams & Wilkins; Volume: 120; Issue: 18 Linguagem: Inglês

10.1161/circulationaha.109.873786

1524-4539

Mehmet Özkan, Murat Biteker, Nilüfer Ekşi Duran, Mustafa Yıldız,

Cardiac Arrhythmias and Treatments

HomeCirculationVol. 120, No. 18Huge Prosthetic Mitral Valve Thrombosis in a Pregnant Woman Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessReview ArticlePDF/EPUBHuge Prosthetic Mitral Valve Thrombosis in a Pregnant Woman Mehmet Özkan, Murat Biteker, Nilüfer Ekşi Duran and Mustafa Yıldız Mehmet ÖzkanMehmet Özkan From the Department of Cardiology, Koşuyolu Kartal Heart and Research Hospital, Istanbul, Turkey. , Murat BitekerMurat Biteker From the Department of Cardiology, Koşuyolu Kartal Heart and Research Hospital, Istanbul, Turkey. , Nilüfer Ekşi DuranNilüfer Ekşi Duran From the Department of Cardiology, Koşuyolu Kartal Heart and Research Hospital, Istanbul, Turkey. and Mustafa YıldızMustafa Yıldız From the Department of Cardiology, Koşuyolu Kartal Heart and Research Hospital, Istanbul, Turkey. Originally published3 Nov 2009https://doi.org/10.1161/CIRCULATIONAHA.109.873786Circulation. 2009;120:e151–e152A 42-year-old woman in her 30th week of pregnancy who had undergone a mitral valve replacement with a 29-mm St. Jude Medical mechanical prosthetic valve (St. Jude Medical, St. Paul, Minn) 2 years earlier was referred to our hospital with severe dyspnea. She had a history of irregular and subtherapeutic use of enoxaparin 6000 IU/d until admission. Transthoracic echocardiography revealed a mean diastolic mitral transvalvular gradient of 29 mm Hg, mitral valve area of 0.6 cm2, and a giant thrombus with mobile components on the prosthetic valve (Figure 1; online-only Data Supplement Movie I). In spite of the large prosthetic mitral valve thrombosis, she had no history of thromboembolism. Two-dimensional transesophageal echocardiography revealed an unprecedentedly large thrombus (6 cm2 in area) appended to the mitral valve that was restricting the movement of 1 of the leaflets (Figure 2; online-only Data Supplement Movie II). Real-time 3-dimensional transesophageal echocardiography demonstrated restriction of 1 of the leaflets with a thrombus located on the left atrial side of the mitral valve (Figure 3; online-only Data Supplement Movie III). After the patient was given a low-dose (25 mg), slow-infusion (6 hours) tissue plasminogen activator without bolus administration 3 times (for a total of 75 mg), 3-dimensional transesophageal echocardiography showed complete thrombolysis (Figure 4; online-only Data Supplement Movie IV). The mean transprosthetic mitral valve gradient decreased to 4 mm Hg, and mitral valve area increased to 2.7 cm2. Download figureDownload PowerPointFigure 1. Transthoracic echocardiography revealed obstruction of the prosthetic mitral valve with a mean diastolic mitral transvalvular gradient of 29 mm Hg and a peak velocity of 3.2 m/s.Download figureDownload PowerPointFigure 2. Two-dimensional transesophageal echocardiography showed a huge thrombus (arrows) on the prosthetic mitral valve (PMV) as the cause of obstruction, with an area of 6 cm2. LA indicates left atrium; LV, left ventricle.Download figureDownload PowerPointFigure 3. Real-time 3-dimensional transesophageal echocardiography from the left atrial side revealed a giant thrombus (arrows) on the prosthetic mitral valve that restricted the movement of the septal leaflet.Download figureDownload PowerPointFigure 4. After the third dose of tissue plasminogen activator, 3-dimensional transesophageal echocardiography showed complete lysis of the thrombus and relief of the restricted valve movements.Prosthetic heart valve thrombosis in pregnancy is a life-threatening complication for which management remains controversial. Although review of the literature for management of prosthetic valve thrombosis in a pregnant patient reveals no set guidelines, thrombolytic therapy, thrombectomy, and prosthetic valve replacement are the currently available options. Surgery is usually favored in the current guidelines1 for the management of obstructive prosthetic valve thrombosis; however, the reported operative mortality, depending on the functional class, can be as high as 69%.2 We have reported previously that the high success rate of thrombolysis performed under 2-dimensional transesophageal echocardiographic guidance is independent of valve location and type, morphological characteristics of the prosthetic valve thrombi, and New York Heart Association class at presentation.3 We have also recently shown that a low-dose, slow infusion of tissue plasminogen activator given in discrete successive sessions guided by serial 2-dimensional transesophageal echocardiography is associated with a low risk of complications and a high rate of success even in patients with obstructive thrombosis and New York Heart Association class III or IV.4The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/120/18/e151/DC1.DisclosuresNone.FootnotesCorrespondence to Murat Biteker, MD, Koşuyolu Kartal Heart and Research Hospital, Cardiology Department, Zeytinlik Caddesi, Emrah Sokak, 7/20, Atalar, Kartal, Istanbul, Turkey. E-mail [email protected]References1 Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2006; 48: e1–e148.CrossrefMedlineGoogle Scholar2 Lengyel M. Diagnosis and treatment of left-sided prosthetic valve thrombosis. Expert Rev Cardiovasc Ther. 2008; 6: 85–93.CrossrefMedlineGoogle Scholar3 Özkan M, Kaymaz C, Kirma C, Sönmez K, Özdemir N, Balkanay M, Yakut C, Deligönül U. Intravenous thrombolytic treatment of mechanical valve thrombosis: a study using serial transesophageal echocardiography. J Am Coll Cardiol. 2000; 35: 1881–1889.CrossrefMedlineGoogle Scholar4 Biteker M, Duran NE, Gündüz S, Kaya H, Kaynak E, Çevik C, Astarcıoğlu MA, Sönmez K, Özdemir N, Kaymaz C, Özkan M. Comparing different intravenous thrombolytic treatment regimens in patients with prosthetic heart valve thrombosis under the guidance of serial transesophageal echocardiography: a 15-year study in a single center (TROIA Trial). Circulation. 2008; 118: S-932. Abstract.Google Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Kalkan M, Yildiz M, Ak H, Zencirkiran Agus H, Ozsahin Y, Aykan A and Oksen D (2020) Safety of low-dose prolonged infusion of tissue plasminogen activator therapy in patients with thromboembolic events in the intensive care unit, Kardiologiia, 10.18087/cardio.2020.7.n1091, 60:7, (86-90) Gündüz S, Kalçık M, Gürsoy M, Güner A and Özkan M (2020) Diagnosis, treatment & management of prosthetic valve thrombosis: the key considerations, Expert Review of Medical Devices, 10.1080/17434440.2020.1733972, 17:3, (209-221), Online publication date: 3-Mar-2020. Biteker M, Başaran Ö, Filiz Başaran N and Sungur Biteker F (2015) Low-dose intravenous tissue-type plasminogen activator for prosthetic valve thrombosis is better than standard dose streptokinase, Revista Portuguesa de Cardiologia (English Edition), 10.1016/j.repce.2015.08.013, 34:9, (569), Online publication date: 1-Sep-2015. Biteker M, Başaran Ö, Filiz Başaran N and Sungur Biteker F (2015) Low-dose intravenous tissue-type plasminogen activator for prosthetic valve thrombosis is better than standard dose streptokinase, Revista Portuguesa de Cardiologia, 10.1016/j.repc.2015.03.008, 34:9, (569), Online publication date: 1-Sep-2015. Kalcik M, Gursoy M, Karakoyun S, Yesin M, Astarcioglu M and Ozkan M (2014) Potential Inherited Causes of Recurrent Prosthetic Mitral Valve Thrombosis in a Pregnant Patient Suffering from Recurrent Miscarriage, Korean Circulation Journal, 10.4070/kcj.2014.44.4.268, 44:4, (268), . Özkan M, Gürsoy O, Astarcıoğlu M, Gündüz S, Çakal B, Karakoyun S, Kalçık M, Kahveci G, Duran N, Yıldız M and Cevik C (2013) Real-Time Three-Dimensional Transesophageal Echocardiography in the Assessment of Mechanical Prosthetic Mitral Valve Ring Thrombosis, The American Journal of Cardiology, 10.1016/j.amjcard.2013.05.032, 112:7, (977-983), Online publication date: 1-Oct-2013. Özkan M, Gündüz S, Yıldız M and Duran N (2009) Diagnosis of the prosthetic heart valve pannus formation with real-time three-dimensional transoesophageal echocardiography, European Heart Journal - Cardiovascular Imaging, 10.1093/ejechocard/jep206, 11:4, (E17-E17), Online publication date: 1-May-2010., Online publication date: 1-May-2010. November 3, 2009Vol 120, Issue 18 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.109.873786PMID: 19884477 Originally publishedNovember 3, 2009 PDF download Advertisement SubjectsEchocardiographyThrombosis