J Cardiovasc Ultrasound.  2013 Dec;21(4):192-196. 10.4250/jcu.2013.21.4.192.

Organized Prosthetic Tricuspid Valve Thrombosis Treated Successfully with Medical Treatment

• Shin HS
• Kim KH
• Lee HS
• Choi HM
• Lee SA
• Park EA
• Kim HK

• KMID: 2135420
• DOI: http://doi.org/10.4250/jcu.2013.21.4.192

Abstract

Prosthetic valve thrombosis (PVT) can be a life-threatening complication that requires immediate treatment. We present a case of 57-year-old woman with tricuspid PVT who was definitely diagnosed by multi-detector-row computed tomography limited with echocardiography. The patient was treated successfully with an alternative approach using low molecular weight heparin bridging therapy followed by intensifying anticoagulation alone.

Keyword

Prosthetic tricuspid valve; Thrombosis; MDCT

MeSH Terms

Echocardiography
Female
Heparin, Low-Molecular-Weight
Humans
Middle Aged
Thrombosis*
Tricuspid Valve*
Heparin, Low-Molecular-Weight

Figure

• 

  Fig. 1 A: Doppler echocardiographic examination before warfarin discontinuation shows the peak E velocity of 1 m/s, peak pressure gradient of 5 mmHg, and normal range of pressure half time of 144 ms. B-D: Transthoracic echocardiography at admission. (B) Doppler echocardiography shows a mosaic pattern of the color Doppler signal at the tricuspid inflow. (C) Continuous Doppler examination demonstrates the mean and peak pressure gradient of 3 mmHg and 5 mmHg (D), and an increased pressure half time of 382 ms across the tricuspid valve.

• 

  Fig. 2 Cardiac computed tomography (valve protocol) showing a large 14 × 6 × 11 mm thrombus on the prosthetic tricuspid valve (white arrows: thrombus, scale bar: 10 mm)

• 

  Fig. 3 Doppler echocardiography after 4 months, demonstrating normalized pressure half time of 182 ms across the prosthetic tricuspid valve.

Reference

1. Vongpatanasin W, Hillis LD, Lange RA. Prosthetic heart valves. N Engl J Med. 1996; 335:407–416. PMID: 8676934.

2. Cannegieter SC, Rosendaal FR, Briët E. Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation. 1994; 89:635–641. PMID: 8313552.

3. Van Nooten GJ, Caes F, Taeymans Y, Van Belleghem Y, François K, De Bacquer D, Deuvaert FE, Wellens F, Primo G. Tricuspid valve replacement: postoperative and long-term results. J Thorac Cardiovasc Surg. 1995; 110:672–679. PMID: 7564433.

4. Thorburn CW, Morgan JJ, Shanahan MX, Chang VP. Long-term results of tricuspid valve replacement and the problem of prosthetic valve thrombosis. Am J Cardiol. 1983; 51:1128–1132. PMID: 6837458.

5. Yaminisharif A, Alemzadeh-Ansari MJ, Ahmadi SH. Prosthetic tricuspid valve thrombosis: three case reports and literature review. J Tehran Heart Cent. 2012; 7:147–155. PMID: 23323074.

6. Zhang DY, Lozier J, Chang R, Sachdev V, Chen MY, Audibert JL, Horvath KA, Rosing DR. Case study and review: treatment of tricuspid prosthetic valve thrombosis. Int J Cardiol. 2012; 162:14–19. PMID: 22000268.

7. Ingram TE, Jones MI, Masani ND. Prosthetic tricuspid valve thrombosis treated successfully with thrombolysis. Heart. 2012; 98:602. PMID: 22285971.

8. Shapira Y, Sagie A, Jortner R, Adler Y, Hirsch R. Thrombosis of bileaflet tricuspid valve prosthesis: clinical spectrum and the role of nonsurgical treatment. Am Heart J. 1999; 137:721–725. PMID: 10097236.

9. Cevik C, Izgi C, Dechyapirom W, Nugent K. Treatment of prosthetic valve thrombosis: rationale for a prospective randomized clinical trial. J Heart Valve Dis. 2010; 19:161–170. PMID: 20369498.

10. Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, Mallery JS, Raddawi HM, Vargo JJ 2nd, Waring JP, Fanelli RD, Wheeler-Harbough J. American Society for Gastrointestinal Endoscopy. Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures. Gastrointest Endosc. 2002; 55:775–779. PMID: 12024126.

11. Lee JK, Kang HW, Kim SG, Kim JS, Jung HC. Risks related with withholding and resuming anticoagulation in patients with non-variceal upper gastrointestinal bleeding while on warfarin therapy. Int J Clin Pract. 2012; 66:64–68. PMID: 22171905.

12. Ananthasubramaniam K, Beattie JN, Rosman HS, Jayam V, Borzak S. How safely and for how long can warfarin therapy be withheld in prosthetic heart valve patients hospitalized with a major hemorrhage? Chest. 2001; 119:478–484. PMID: 11171726.

13. Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, Grayburn PA, Khandheria BK, Levine RA, Marx GR, Miller FA Jr, Nakatani S, Quiñones MA, Rakowski H, Rodriguez LL, Swaminathan M, Waggoner AD, Weissman NJ, Zabalgoitia M. American Society of Echocardiography's Guidelines and Standards Committee. Task Force on Prosthetic Valves. American College of Cardiology Cardiovascular Imaging Committee. Cardiac Imaging Committee of the American Heart Association. European Association of Echocardiography. European Society of Cardiology. Japanese Society of Echocardiography. Canadian Society of Echocardiography. American College of Cardiology Foundation. American Heart Association. European Association of Echocardiography. European Society of Cardiology. Japanese Society of Echocardiography. Canadian Society of Echocardiography. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound:a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, developed in conjunction with the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2009; 22:975–1014. PMID: 19733789.

14. Montorsi P, De Bernardi F, Muratori M, Cavoretto D, Pepi M. Role of cine-fluoroscopy, transthoracic, and transesophageal echocardiography in patients with suspected prosthetic heart valve thrombosis. Am J Cardiol. 2000; 85:58–64. PMID: 11078238.

15. Symersky P, Budde RP, de Mol BA, Prokop M. Comparison of multidetector-row computed tomography to echocardiography and fluoroscopy for evaluation of patients with mechanical prosthetic valve obstruction. Am J Cardiol. 2009; 104:1128–1134. PMID: 19801036.

16. Tsai IC, Lin YK, Chang Y, Fu YC, Wang CC, Hsieh SR, Wei HJ, Tsai HW, Jan SL, Wang KY, Chen MC, Chen CC. Correctness of multi-detector-row computed tomography for diagnosing mechanical prosthetic heart valve disorders using operative findings as a gold standard. Eur Radiol. 2009; 19:857–867. PMID: 19037643.

17. Teshima H, Hayashida N, Fukunaga S, Tayama E, Kawara T, Aoyagi S, Uchida M. Usefulness of a multidetector-row computed tomography scanner for detecting pannus formation. Ann Thorac Surg. 2004; 77:523–526. PMID: 14759431.

18. 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. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2008 focused update incorporated into the 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). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008; 52:e1–e142. PMID: 18848134.

19. Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, Baumgartner H, Borger MA, Carrel TP, De Bonis M, Evangelista A, Falk V, Iung B, Lancellotti P, Pierard L, Price S, Schäfers HJ, Schuler G, Stepinska J, Swedberg K, Takkenberg J, Von Oppell UO, Windecker S, Zamorano JL, Zembala M. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J. 2012; 33:2451–2496. PMID: 22922415.

20. Al Habib HF, Tarola C, Diamantorous P, Chu MW. Successful treatment of mechanical mitral valve thrombosis without thrombolytic therapy or surgery. Can J Cardiol. 2013; 29:1532.e1–1532.e3. PMID: 23639269.