Author + information
- Saide Aytekin, MD⁎ (, )
- Yelda Tayyareci, MD,
- Ozlem Yildirimturk, MD,
- Selen Yurdakul, MD,
- Ertan Sagbas, MD,
- Ilhan Sanisoglu, MD,
- Ahmet Ozkara, MD and
- Belhan Akpinar, MD
- ↵⁎Florence Nightingale Hospital, Department of Cardiology, Abide-i Hurriyet cad. number: 290, Caglayan, Istanbul, Turkey 34381
Despite being mechanical and prosthetic, heart valve rings (HVR) are known to have a lower risk of thrombosis compared with prosthetic mechanical heart valves, thus anticoagulation therapy is only recommended within 3 months after the surgery according to the current guidelines (1). We present 4 cases in which HVR thrombi were obtained by transesophageal echocardiography (TEE) as a novel finding with HVR.
The first case was a 41-year-old woman who had a mitral HVR operation 3 months before her admission with acute atrial fibrillation and who was a candidate for electrical cardioversion. She was referred for TEE to exclude the presence of left atrial (LA) thrombus when we incidentally observed multiple hyperechogenic, mobile thrombus images on the prosthetic mitral ring (Sorin ring, number: 34, Sorin Group, Milan, Italy) (Fig. 1A, Online Video 1A). Her international normalized ratio (INR) was effective (2.6) on admission. As a result of having a history of embolic stroke 1 year previously, the patient was given a low-dose (25 mg), slow-infusion (6 h) tissue-type plasminogen activator (TPA) without bolus administration 2 times (for a total of 50 mg), and as a result, TEE showed an unsatisfactory regression in the thrombi (Fig. 1B, Online Video 1B). We decided to follow up the patient under effective anticoagulation because she refused both the repeat dose of TPA and choice of surgery.
The second case was a 61-year-old woman who had mitral valve replacement (ATS, number: 27, ATS Medical, Inc., Minneapolis, Minnesota) and tricuspid valve annuloplasty (Sorin ring, number: 34, Sorin Group) operation 3 months before her admission with progressive severe dyspnea. TEE revealed 3 big nonobstructive thrombi (2.9 × 1.0 cm, 2.4 × 1.3 cm, and 1.2 × 0.8 cm, respectively) over the prosthetic tricuspid ring, which were relocating from right atrium to right ventricle in every diastole (Fig. 1C, Online Video 1C). Because she had elevated pulmonary artery pressure (PAP) (60 mm Hg), we also performed thoracic computed tomography for a suspected pulmonary embolism, but the pulmonary arteries were clear of thrombus. It was surprising to obtain thrombus on the tricuspid ring despite having effective INR levels (3.4) and a mechanical prosthetic mitral valve clear of thrombus. Because the thrombi were big and extremely mobile, the patient was considered to be high risk and was offered surgery. Because she refused the operation, again low-dose, slow-infusion TPA was performed 3 times (for a total of 75 mg). Control TEE revealed minimal regression in the thrombus sizes (Fig. 1D, Online Video 1D). The patient refused further treatment and was discharged with effective-dose anticoagulation.
The third case was a 40-year-old asymptomatic woman who was admitted for routine echocardiographic examination 3 months after having aortic and mitral valve replacement and a tricuspid annuloplasty operation. After obtaining suspected thrombus images on tricuspid ring in transthoracic echocardiography, we observed 2 hyperechogenic, mobile masses (1.5 × 0.8 cm and 0.78 × 0.5 cm in size) over the tricuspid annuloplasty ring (Sorin ring, number: 34, Sorin Group) causing a 2.8 mm Hg transtricuspid gradient in TEE examination (Fig. 2A, Online Video 2A). Despite having an ineffective INR (1.68) this time, similar to the second case, both the mechanical prosthetic mitral and aortic valves were free of thrombus. Because the thrombi were obstructive, we performed low-dose, slow-infusion TPA 2 times (for a total of 50 mg), and significant regression in both thrombi sizes and transtricuspid gradient (1.2 mm Hg) was provided (Fig. 2B, Online Video 2B).
The last case was a 68-year-old man who presented with acute pulmonary edema with a history of coronary artery bypass graft surgery and mitral annuloplasty (Sorin ring, number: 32, Sorin Group) 1 year previously. TEE revealed an obstructive 1.16 × 0.7 cm, hyperechogenic, mobile mass over the prosthetic mitral ring causing an 11.8 mm Hg mean transmitral gradient and elevated PAP (65 mm Hg) (Fig. 2C, Online Video 2C). He was on anticoagulation therapy due to atrial fibrillation, but his INR (1.5) was ineffective. Because of the obstructive pattern of the thrombus, we administrated low-dose, slow-infusion TPA 3 times (for a total of 75 mg) in this case. Thrombus seemed to be smaller, but the transmitral gradient was still high (8.9 mm Hg) (Fig. 2D, Online Video 2D). Because the patient rejected the surgical option, we decided to follow him up under effective anticoagulation. One year later, he was re-admitted to our hospital with acute pulmonary edema again caused by an obstructive mitral ring thrombus; he urgently underwent cardiac surgery and had a successful clinical outcome.
These cases are interesting because 2 of them were asymptomatic and were incidentally diagnosed, whereas 3 of the patients were diagnosed within 3 months after the annuloplasty operation, such that they were still on anticoagulation. Having thrombus-free prosthetic valves in 2 of the cases accompanying the presence of valve ring thrombosis is also challenging. We think that more attention should be paid to prosthetic heart valve rings because of their potential for the increased risk of thrombosis.
For supplemental videos, please see the online version of this paper.
- American College of Cardiology Foundation