[Right-sided prosthetic cardiac valve thrombosis: value of cinefluoroscopy in the diagnosis and follow-up of thrombolytic treatment]

Author(s): Hobbach HP, Mall K, Schaeffer C, Schuster P

Affiliation(s): Medizinische Klinik II, St. Marien-Krankenhaus Siegen. hp.hobbach@marienkrankenhaus.com

Publication date & source: 2009-10, Dtsch Med Wochenschr., 134(41):2059-63. Epub 2009 Oct 2.

Publication type: Case Reports; English Abstract

HISTORY: A 33-year-old woman (Pt. A) with a prosthetic cardiac valve in the pulmonary position [CarboMedics bileaflet valve, diameter 23 mm] as part of the repair of a tetralogy of Fallot 4 years previously, and a 51-year-old woman (Pt. B) with a prosthetic cardiac valve [St. Jude Medical bileaflet valve, diameter 31 mm] inserted in tricuspid position as replacement of a degenerated Hancock bioprosthetic valve inserted 15 years previously, 10 years after an episode of endocarditis, were admitted to hospital with dyspnea and chest pain and dyspnea and tachycardia, respectively. INVESTIGATIONS: Pt. A had a 3 - 4/6 crescendo-decrescendo systolic murmur and a 2/6 early diastolic decrescendo murmur over the 2nd to 4th right intercostal space (ICS), while Pt. B had a 3/6 holosystolic murmur and a 2 - 3/6 diastolic murmur over the 4th right ICS. Closing click was missing in both patients. Blood tests demonstrated an elevated LDH (404 U/l) in Pt. A and an elevated GGT (108 U/l) and fibrinogen (449 mg/dl) in Pt. B. Anticoagulation was below the therapeutic level, with an INR value of 1,65 and 1,93, respectively. The electrocardiogram showed sinus rhythm, right bundle branch block and an isoelectric ST-segment (Pt. A) and a typical high-frequency atrial flutter with a 2:1 block, right bundle branch block and terminal T-wave inversions in leads V1 to V5 (Pt. B). Cinefluoroscopy showed rigid and hypomobile leaflets as a result of prosthetic cardiac valve thrombosis. Doppler echocardiography confirmed the stenosis of the prosthetic valve in the pulmonary position (peak gradient 73 mm Hg, mean gradient 34 mm Hg) and the tricuspid position (mean gradient 8.48 mm Hg, peak gradient 16.73 mm Hg). TREATMENT AND COURSE: Both patients were treated with unfractionated heparin and urokinase single-bolus injection of 4400 U/kg over 10 min followed by an infusion of 4400 U/kg/h over 12 h. Both patients had an abnormal opening angle, which improved to a normal opening and closing angle. Doppler echocardiography demonstrated decreased peak (18.0 and 6.6 mm Hg, respectively) and median gradients (9.0 and 2.6 mm Hg, respectively). No further complications (such as bleeding, embolism, delayed surgical treatment, rethrombosis) had occurred, and both patients became asymptomatic. After oral anticoagulation in a therapeutic INR range for 12 and 4 months, respectively, prosthetic heart valve function continued to be normal in both patients. CONCLUSION: Thrombolysis appears to be an efficacious and safe treatment in patients with thrombosis of a prosthetic cardiac valve in the pulmonary or tricuspid position, and it may be used as first-line therapy. Cinefluoroscopy is a simple and accurate method both in the diagnosis of prosthetic cardiac valve thrombosis and in following the response to thrombolytic treatment. Copyright Georg Thieme Verlag KG Stuttgart . New York.