Prosthetic heart valve thrombosis can be treated with thrombolytic therapy or surgery. Thrombolytic therapy involves infusing a drug like streptokinase to dissolve the thrombus. The success rate of thrombolytic therapy is around 80% based on studies, with complete hemodynamic improvement observed in most cases. However, embolic events can still occur in around 20% of patients. Current guidelines recommend considering thrombolytic therapy for all NYHA classes of heart failure if individual patient factors support it over surgery. The optimal approach is to individualize treatment based on symptoms, thrombus burden, and surgical risk.

1. PROSTHATIC VALVE THROMBOIS
KEFELEGN D
CCE
24/10/19

2. OUTLINE
• History
• Types
• Pathophysiology
• Diagnoses
• Management ,Literatures And Guidelines

3. History
• The pioneering efforts of Dr. Charles Hufnagel,
who made the first successful placement of a
totally mechanical valvular prosthesis, started the
era of artificial heart valves.
• Hufnagel achieved this feat in 1952, by inserting
a Plexiglas cage containing a ball occluder into the
descending thoracic aorta.
• The first implant of a mitral valve replacement in
its anatomic position took place in 1960, when
the Starr-Edwards prosthesis was put the clinical
use

4. • Prosthetic valve thrombolysis: history – In 1971, Luluaga
et al
• were the first to use the thrombolytic therapy in prosthetic
valve thrombosis.
• Streptokinase was used for treating thrombosis of the
tricuspid valve prosthesis.
• Three years later, Baille et al reported the use of that
thrombolytic agent in the aortic valve prosthesis.

8. Types of prosthetic valves and thrombogenicity
Type of valve Model Thrombogenicity
Mechanical
Caged ball Starr-Edwards ++++
Single tilting disc Bjork-Shiley,Medtronic
Hall
+++
Bileaflet St Jude Medical,Sorin
Bicarbon,Carbomedic
s
++
Bioprosthetic
Heterografts Carpentier-
Edwards,Tissue Med
(Aspire), Hancock II
+ to ++
Homografts +

9. Bileaflet valve
Adv –
• Low bulk - flat profile
• Less thrombogenicy
• Central laminar flow
• two semicircular discs that
pivot between open and
closed positions
• No need for supporting struts
• Good hemodynamics even in
small sizes
• 2 lat ,1 central minor orifice ,
no chance of sudden catastro
thrombosis
Disadv-
• Anticoagulation
mandatory
• risk of thrombosis
St. Jude Medical mechanical heart valve
Carbomedics
Titanium housing
Pyrolytic carbon

11. PROSTHETIC HEART VALVE
THROMBOSIS: MECHANISMS

12. CLINICAL PRESENTATION
• Patients with PV dysfunction with or without thrombosis may
present with progressive dyspnea and signs of heart failure or
systemic embolization.
• Alternatively, PV thrombosis may be an incidental finding at the
time of echocardiographic follow-up.
• PV dysfunction should be suspected in patients with symptoms of
acute or subacute onset associated with an increase in
transprosthetic gradient compared with the last echocardiographic
follow-up
• Although arterial TE after surgical or transcatheter heart valve
replacement should be considered prosthesis-related until proven
otherwise. it may also arise from different cause.
• Reduced or absent click, murmur.

14. DIAGNOSIS
• LAB TEST
• IMAGING

17. TTE
• Regardless of the anatomic location of the prosthesis, the
first-line imaging test for PV dysfunction is TTE.
• Although it is helpful for evaluating prosthetic valve
hemodynamics and valve motion, the test is limited for
morphological characterization of the etiology of PV
dysfunction.
• Acoustic shadowing caused by the prosthesis may limit
visualization of thrombus, vegetations, and pannus.
• The diagnostic accuracy of TTE is influenced by other
factors, such as the presence of pericardial effusion,
emphysema, obesity, or prior sternotomy

21. TEE
• TEE should be considered to better evaluate the
pathological substrate of PV dysfunction.
• In particular, TEE should always be performed if the
transthoracic echocardiography is technically
suboptimal, if the findings are not definitive, or if there
is strong clinical suspicion of PV dysfunction.
• TEE is superior to TEE for evaluating PV dysfunction,
regardless of the valve type.
• Although it is superior to TTE for identifying the
mechanism of PV degeneration, even TEE cannot
reliably discriminate between PV thrombosis and
fibrotic pannus ingrowth

23. Cinefluoroscopy

29. MULTIDETECTOR COMPUTED
TOMOGRAPHY
• In patients with inconclusive TTE and TEE findings (which
may be rather frequent), multidetector computed
tomography could provide an accurate evaluation of the
prosthetic valve structure and functional status
• MDCT scanning may also help to differentiate between PV
dysfunction and patient–prosthesis mismatch for 2 main
reasons:
• 1) it will detect thrombus, vegetations, or other masses;
and
• 2) it provides a more accurate assessment of the geometry
of the left ventricular outflow tract and the effective orifice
area for prostheses implanted in the aortic position

31. Management

42. • Outcome of treatment has been generally categorized
into “complete success,” “partial success,” or
“ineffective.”
• The search eventually yielded 17 studies, comprising
756 patients , which were related to thrombolytic
agents in OTPHV and 13 studies, comprising 662
patients, which were related to surgery in OTPHV

43. PANUS/THROMBUS
• Ten studies presented
data regarding
findings of thrombus
and/or pannus at the
time of surgery for a
total of 518 patients
41% had thrombus
only, 38% had pannus
only, and 21% had
both thrombus and
pannus.

44. How was INR ??

49. • The infusion dosage of streptokinase was a
bolus of 250,000 U in 30 minutes, followed by
100,000 U/h.
• Doppler echocardiography was used to
monitor the time of infusion of the
thrombolytic agent and to assess its efficacy

50. • The criteria for interrupting infusion were as
follows:
• 1.Hemodynamic improvement, assessed on
echocardiography;
• 2. Occurrence of major bleedings or
hemorrhagic stroke.
• 3. Infusion time of 72 hours.

51. • Complete hemodynamic improvement was observed in
81.8% of the patients, partial improvement in 10%,and
treatment failure in 8.2%.
• An embolic event occurred in 19.1% of the patients during
treatment.
• The success of thrombolysis was not influenced by the age
of the patients, the time of symptom onset, the time of
surgery, and the type or position of the valve prosthesis.
• Atrial fibrillation was a predictor of embolic events.

53. • The thrombolytic agent should be interrupted at the 24 th
hour of treatment, if no hemodynamic improvement
(improvement in the gradient) occurs.
• It should be interrupted after 72 hours, even if the
improvement is partial, or should be interrupted earlier, if
the hemodynamic improvement is complete

55. ACC 2017

61. CONCLUSION
• Prosthetic valve thrombosis rate higher than the actual
incidence
• Approach could be to individualize the treatment
depending on NYHA class, thrombus burden, and
availability of surgery.
• Newer regimen of very low-dose, slow infusion leads to
equal efficacy with lower complication in majority of
patients
• According to recent guidelines thrombolysis considered
in all classes of NYHA if individual patient
characteristics support the recommendation of one
treatment over the other.