(Circulation. 1995;91:103-110.)
© 1995 American Heart Association, Inc.
Articles |
Transesophageal Echocardiography for the Diagnosis and Management of Nonobstructive Thrombosis of Mechanical Mitral Valve Prosthesis
From the Department of Cardiology, University Hospital Dupuytren, Limoges, France.
Correspondence to P. Gueret, MD, Department of Cardiology, University Hospital Henri Mondor, 51 avenue du Mal de Lattre de Tassigny, 94010 Creteil, France.
Background Diagnosis of a mechanical mitral valve prosthesis thrombosis is currently made with transthoracic Doppler echocardiography and occasionally with fluoroscopy. However, identifying a thrombus on a valve prosthesis may be difficult, especially if the thrombus is nonobstructive. To prospectively define the role of transesophageal echocardiography for identification of nonobstructive thrombi, we studied a series of patients in whom the prosthetic valve was considered to function normally on clinical examination and transthoracic echocardiography.
Methods and Results One hundred fourteen consecutive patients
with mechanical mitral valve prosthesis were investigated by both
transthoracic echocardiography and transesophageal echocardiography.
These examinations were performed for recent systemic emboli (15
patients), fever of unknown etiology (11 patients), routine
postoperative evaluation (56 patients), and other reasons (32
patients). Based on transthoracic echo diagnosis, all prostheses
were considered normal. Yet, in 20 patients transesophageal
echocardiography revealed the presence of a 2- to 15-mm-long mobile
thrombus localized on the atrial surface of the prosthesis. When
compared with the remaining 94 patients with no visible thrombi, there
was no significant difference between the two groups in terms of
incidence of atrial fibrillation (65% versus 52%), left atrial size
(48±9 versus 51±13 mm), left ventricular end-diastolic
diameter (49±10 versus 51±13 mm) and fractional shortening
(28±9%
versus 31±10%), presence of spontaneous contrast in the left atrium
(40% versus 41%), transprosthetic mean pressure gradient (4.0±1.4
versus 3.9±1.5 mm Hg), or the type of prosthesis used. After we
discovered a nonobstructive thrombosis, patients were treated with
heparin (n=9) or oral anticoagulation (n=11). The presence of a
localized thrombus was confirmed in 3 patients who were operated on. In
the present study, evolution appeared to depend on thrombus size:
of 14 patients exhibiting a small (<5 mm) thrombus, 10 had an
uneventful course, whereas 5 of 6 patients with a large (
5 mm)
thrombus developed complications or died.
Conclusions Transesophageal echocardiography appears to be a reliable method to diagnose thrombi on a mechanical mitral valve prosthesis, even when transthoracic Doppler echocardiographic parameters appear to be normal. Transesophageal echo assessment of thrombus size may be helpful in deciding whether a patient with mitral prosthesis should be treated by anticoagulation, thrombolysis, or valve rereplacement. .
Key Words: valves • prosthesis • echocardiography • thrombosis
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