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J Am Coll Cardiol, 2004; 43:77-84, doi:10.1016/j.jacc.2003.08.028 © 2004 by the American College of Cardiology Foundation |
* Baylor College of Medicine, Houston, Texas, USA
Hopital Cardiologique Du Haut Leveque, Pessac, France
Kosuyolu Heart and Research Hospital, Istanbul, Turkey
Rabin Medical Center, Petah-Tikva, Israel
|| King Faisel Specialist Hospital and Research Center, Riyadh, Saudi Arabia
¶ Instituto Dante Pazzanes E. de Cardiologia, San Paulo, Brazil
# Hospital De La Santa Creu I Sant Pau, Barcelona, Spain
** Mayo Clinic, Rochester, Minnesota, USA
American University of Beirut, Beirut, Lebanon
Texas Heart Institute, Houston, Texas, USA
Massachusetts General Hospital, Boston, Massachusetts, USA
Manuscript received February 19, 2003; revised manuscript received August 4, 2003, accepted August 11, 2003.
* Reprint requests and correspondence: Dr. William A. Zoghbi, Echocardiography Laboratory, The Methodist DeBakey Heart Center, 6550 Fannin, SM-677, Houston, Texas 77030, USA.
wzoghbi{at}bcm.tmc.edu
OBJECTIVES: The goal of this study was to evaluate whether quantitation of thrombus burden with transesophageal echocardiography (TEE) can help risk-stratify patients undergoing thrombolysis of prosthetic valve thrombosis (PVT).
BACKGROUND: Thrombolytic therapy of PVT has an unpredictable risk of embolization and complications.
METHODS: An international registry of patients with suspected PVT undergoing two-dimensional/Doppler and TEE before thrombolysis was established. All TEE studies were reviewed and quantitated by a single observer blinded to all data.
RESULTS: From 1985 to 2001, 107 patients (71 females; age 24 to 86 years) from 14 centers (6 in the U.S.) were identified. The majority of cases involved the mitral valve (79 mitral, 13 aortic, and 15 tricuspid). Hemodynamic success rate was achieved in 85% and was similar across valves. Overall complications were observed in 17.8%, and death in 5.6%. Predictors of complications were: New York Heart Association (NYHA) functional class, presence of shock, sinus tachycardia, hypotension, previous history of stroke, thrombus extension beyond the valve ring, and thrombus area. Multivariate analysis demonstrated that two variables were independent predictors of complications: thrombus area by TEE (odds ratio [OR] 2.41 per 1 cm2 increment, 95% confidence interval [CI] 1.12 to 5.19) and prior history of stroke (OR 4.55, 95% CI 1.35 to 15.38). A thrombus area <0.8 cm2 identified patients at lower risk for complications from thrombolysis, irrespective of NYHA functional class.
CONCLUSIONS: In PVT, the thrombus size imaged with TEE is a significant independent predictor of outcome. Transesophageal echocardiography can identify low-risk groups for thrombolysis irrespective of symptom severity and is therefore recommended in the management of prosthetic valve thrombosis.
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