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Circulation, Vol 87, 30-37, Copyright © 1993 by American Heart Association
H Silber, SS Khan, JM Matloff, A Chaux, M DeRobertis and R Gray
BACKGROUND. Thrombolytic therapy is a promising alternative to valve
replacement in the management of prosthetic valve thrombosis. We sought to
determine the short- and long-term results of treating thrombosed St. Jude
heart valves with thrombolytic therapy as the primary treatment modality.
METHODS AND RESULTS. Between March 1978 and December 1991, 988 patients
underwent implantation of St. Jude prosthetic valves at our medical center,
and all patients with thrombosed valves were identified prospectively.
During this period, 17 patients (13 women; mean age, 66.8 +/- 19.0 years)
developed prosthetic valve thrombosis (11 aortic, six mitral). In six
patients, Coumadin was stopped in preparation for elective surgery. The
clinical presentation was congestive heart failure in 13, syncope and
fatigue in two, and a cerebrovascular accident in one; one patient was
asymptomatic. The average duration of symptoms was 11.7 +/- 12.0 days
(range, 1-45 days). Anticoagulation was subtherapeutic in all but one
patient at the time of presentation. Cinefluoroscopy was the primary method
used for diagnosis and was also used to follow the response to therapy.
Twelve patients were treated medically (10 with thrombolytic therapy and
two with heparin), three were treated surgically, and two were diagnosed at
autopsy. Of the 12 medically treated patients, 10 had marked improvement in
leaflet movement and symptoms within 12 hours. Thus, 10 of 12 patients
(83%) had a satisfactory response to medical therapy alone. No medically
treated patient died or had a major complication resulting in permanent
damage. However, four of the 12 medically treated patients had minor
complications, including a transient episode of facial weakness in one
patient, hematomas in two, and epistaxis in one. Late rethrombosis recurred
in two patients in the medically treated group and was successfully
retreated with thrombolytic therapy. At 3 months, all patients were alive
and well. CONCLUSIONS. Thrombolytic therapy can be used as the first line
of therapy for thrombosed St. Jude valves with a low risk of permanent side
effects and excellent chances of success. In most cases, surgery can be
reserved for patients who do not respond to thrombolytic therapy.
ARTICLES
The St. Jude valve. Thrombolysis as the first line of therapy for cardiac valve thrombosis
Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA 90048.
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