TREATMENT OF OBSTRUCTIVE THROMBOSED PROSTHETIC HEART VALVE
Shabuddin H. Rahimtoola, M.D., University of Southern California, Los Angeles, CA, USA
A systematic review of the literature from 1996 -2012 revealed 9 studies with 48 patients with tricuspid OT PHV in whom thrombolytic therapy was successful in 88%. For left sided OT PHV, 17 studies comprising 756 patients had received thrombolytic therapy (TT) and in 13 studies comprising 662 patients had received surgical therapy (ST). Females were present 59% (TT) and 66% (ST). All but 3 patients had a mechanical valve. In 10 ST comprising 518 patients, thrombus was present in 41%, pannus in 38%, thrombus + pannus in 21%. Anticoagulants were described as inadequate in 39%. Mitral valve was involved in 68% (TT), 73% (ST); remainder had aortic valve; NYHA Class III/IV 65% (TT) 81% (ST); remainder were in NYHA Class I/II. Recurrence rate was 13% (TT) 6% (ST); CVA/Emboli 14% (TT) 6% (ST). In TT, complete success was 70%. 30 day mortality was 8%. In (TT) failure rate was 30% with mortality up to 28%. In TT Failure group, 15 patients died while waiting for surgery. In ST, complete success occurred in 100% with 30 day mortality of 15%. Suggested therapeutic strategies: Tricuspid OT PHV Thrombolytic TT is first choice. Left sided OT PHV: TT first choice in NYHA FCI/II, those with very severe co-morbid conditions, ST not a viable option or patient refuses surgery. Left sided OT PHV: ST is first choice if prosthesis replacement is necessary or appropriate, coronary flow is compromised TT is contraindicated, pannus is a significant contributor, TT fails.