Downloaded 62 times
Uploaded byAmir Mahmoud
Prosthetic heart valve obstruction
1. Prosthetic valve obstruction can be life-threatening, with morbidity and mortality rates ranging from 0.1-6% per patient year depending on the valve type and position. 2. Thrombus, pannus, and vegetation are common causes of prosthetic valve obstruction. Predictors include valve type, anticoagulation status, valve position, atrial fibrillation, and ventricular dysfunction. 3. Treatment depends on the location and size of obstruction, functional status, and surgical risk. For left-sided obstruction, surgery is generally preferred but thrombolysis may be considered for lower risk patients with smaller thrombi.
More Related Content
Similar to Prosthetic heart valve obstruction
Prosthetic heart valve obstruction
- 1. Prosthetic Heart ValveObstruction: Thrombolysis or Surgery Taher Elkady, MD National Heart Institute
- 2. Prosthetic Valve ObstructionPVO Life threatening morbidity & mortality 0.1% - 6% per patient year (left) 20% in of tricuspid valve Thrombus Pannus Vegetation
- 3. Predictors of Prosth.Valve Thrombosis PVT Valve type Anticoagulation status Valve position Atrial fibrillation Ventricular dysfunction Inadequate anticoagulant therapy
- 4. Pathophysiology Prosthetic valve thrombosiPVT Thrombus ++ mechanical valves Platelet & blood cells Xx endocardium Surface of the Metabolic/structural Immed after surgery mechanical valve changes due to irregular flow At hignes 1st 3 – 6 post implant (10%) ++ Mitral
- 5. PVT: Sites 1. Suturesites 2. Prosthesis material Bioprostheses PVT is less frequent (0.03% per year) ++ 1st months post-surgery Endothelization of the sewing ring
- 6. Pannus Ingrowths Fibro C.T.ingrowths Swing ring Many years post implant Aortic position / prost. Ring of mitral repair Thrombus on a Pannus
- 7. Clinical Presentation OPVT systemicembolization, fatigue, SOB (weeks) Acute hemodynamic collapse & death NOPVT Minimal S & S, stable Embolic potential IEC blood cultures P/E PV sounds, a new murmur Changes of a previous murmur Diagnosis TTE, TEE, Fluoroscopy, MSCT
- 8. Tranthoracic Echo (TTE) ??Acoustic shadowing Best for: Transvalvular gradient thrombolysis Mitral prosthesis Early peak velocity Mean PG DVI, PHT, EOA (continnuty) TR RVSP/PGT Aortic prothesis Peak /PG DVI, EOA P.S flow velocity does not reflect PVD
- 9. Causes of flowvelocity –PVO –High-output status –Severe prosthesis regurgitation –Patient prosthesis mismatch TEE, Fluoro, MSCT
- 10. Transesophageal Echocardiography TEE •Thrombus size & location • D.D. Pannus: thrombus: vegitation • Mitral & Tricuspide prosthesis • Aortic bioprosthesis • Aortic homograft • Other causes of prosthesis obstruction • Small thrombus vs. prosthesis filaments (fibrin) ++ in AA & AV replacement
- 11. TEE in PVO PannusThrombus Size smaller larger Echogenicity echodense echosoft (lucent) = myocardium Valve mechanism - no effect block all valve - valve stifening mechanisme - xx valve closure /opening
- 12. TEE: PVO Thombus sizeTreatment strategy Thrombolysis TEE (+ Doppler) Serial hemodynamic success of fibrinolysis Tong, Rondaut et al. JACC 2004 (Pro – TEE registry) Left –sided OPVT: Thrombus Area <0.85 cm Risk for embolism/death with thrombolysis
- 13. Other causes ofPVO • Mitral chordal remnants • Longer sutures • Unraveled sutures • LVOTO with AML retention in MV repair
- 14. Cinefluoroscopy Prosthesis valve motion •Opening and closing angles • Motion of the base ring of P • Leaflet motion in mechanical Ao. P
- 15. Multidetector cardiac C.T •Disc mobility = fluoro • Pannus vs. thrombus ++ in aortic P • Biological leaflet thickening /restriction • Serial assessment Limitations Atrial fibrillation SOB / poor functional class
- 16. Realtime 3-Dimensional TEE Enfacevisualization of P Promising ++ thrombus/Pannus
- 17. PVT: Treatment • Location •Size • Functional class • Risk of surgery • Risk of thrombolysis • experience
- 18. Left-sided OPVT • EmergencySurgery Valve replacement Thrombectomy • Thrombolysis No RCTs to compare the two methods
- 19. Guidelines dilemma: • Whichis the ttt of choice? • Major determinants of treatment • Functional class • Thrombus size • OPVT/NOPVT
- 20. Surgery in leftsided OPVT ECS (2007) / ACC-AHA (2008) guidelines Surgery in the ttt of choice Operative mortality (5% - 18%) & NYHA class 4-7% in class I-III & 17.5 – 31.3% in class IV
- 21. Thrombolysis in Lt.sided OPVT Earlier studies Thrombolysiis the heparin MR systemic embolisim bleeding, rethrombosis Rondaut et al. arch C.V Dise 2009 Surgery Thrombolysis Mortality 10% 10% Hemody. Success 81% 70.9% Embolic episode 0.7% 1% Total complications 11% 25% Thrombolysis is warranted only as a rescue procedure
- 22. Thrombolysis Hemodyn. Success 64- 89% Systemic emboli 5 – 19% Major bleeding 5 – 8% Recurrence 15 – 31% Mortality 6 – 12.5% • Roudant R et al. JACC 2004 • Loriga FM et al. J thrombolysis 2006 • Nagy A et al. J Heart valve dise. 2009 • Keuleers S et al. AJC, 2011
- 23. NYHA – IVMortality: 7% post thromb 17% post surgery NYHA: I – III Mortality: 5% in both Thrombus < 14 days higher fibrinolysis chance of success i.e Chronic thrombosis surgery (Pannus)
- 24. FAQ Failed thrombolysis? Surgery Partialsuccess? Surgery Surgery post thrombolysis when? • 24 hrs after the discontinuation of the infusion • 2 hrs after neutralizing fibrinolytic activity by protease inhibition
- 25. Thrombolitic agents Skase, Urokinase,rt-PA Protocols: as pulmonary thromboimbolism 1. Skase: 250000 I.U/30 min 100000 IU/hr for 72 – 96 hrs 2. Urokinase: 4400 U/kg/hr for up to 12 hrs 3. Rt-PA: 10 – 15 mg boluses 90 mg 85 mg over 90m – 180 min (total dose 100 mg Recently: Rt-PA 25 mg bolus slow infusion (over 6 hrs) Lower MR (for bleeding)
- 26. Rt. Side PVT Fibrinolysisof choice failed Surgery Pannus, contraindication to thrombolysis Surgery Watch: PFO or ASD
- 27. Recurrent Episodes ofPVT Surgery of choice + Pannus Fibrinolysis less effective How to avoid? Add ASA (I,D) INR Valve replacement by a bioprosthesis
- 28. NOPVT & size– Embolism • Small < 5mm length, asymptomatic Medical ttt: anticoagulant Rx, add ASA • Long thrombus or embolic Thrombolysis or surgery
- 29. Conclusion • PVT canbe a medical emergency with mortality • TEE plays an important role to diagnosis • TEE provides incremental information about success of therapy • Management in design and performance of metallic & bioprosthesis, together within the use of new direct thrombin & Xa inhibitors New perspectives for the further management of pts with PVT