Shapira Y, Sagie A, Jortner R, Adler Y, Hirsch R
Sheingarten Echocardiography Unit, Department of Cardiology, Tel-Aviv University, Tel-Aviv, Israel.
Am Heart J. 1999 Apr;137(4 Pt 1):721-5. doi: 10.1016/s0002-8703(99)70229-2.
Thrombosis of a mechanical tricuspid valve prosthesis is a potentially hazardous event. This study aimed to explore the incidence and the clinical presentation of tricuspid valve thrombosis occurring in bileaflet valves and to evaluate the diagnostic and the therapeutic approach.
Tricuspid valve thrombosis was sought in 22 late survivors with the CarboMedics valve in a follow-up period of 36.0 +/- 20.8 months. Limited leaflet motion and/or a visible thrombus were considered diagnostic of valve thrombosis. Eight episodes of tricuspid valve thrombosis were diagnosed among 5 patients (12.1 episodes per 100 patient-years). Anticoagulation was inadequate in 3 patients and fair in 2. Florid right heart failure occurred in 3 episodes. Common physical findings included increased jugular venous pulse (5 patients), diastolic tricuspid murmur (4 patients), and peripheral edema (4 patients). The diagnosis was suspected in all clinically and by transthoracic echocardiography and confirmed by fluoroscopy and/or transesophageal echocardiography. In 4 patients, both leaflets were involved. No thrombi were visualized. Three patients received thrombolytic therapy in 4 episodes (complete success in 3, partial success in 1) without hemorrhagic or embolic complications. One patient responded to aggressive anticoagulant therapy. One patient required an emergent repeat surgery. In 1 patient, valve thrombosis recurred thrice.
In patients with fair or poor anticoagulation, a bileaflet valve in the tricuspid position is associated with a high incidence of valve thrombosis. Hinge entrapment requires only a small amount of thrombotic material. Valve thrombosis may be asymptomatic. Involvement of both leaflets is usually required to produce symptoms. A nonsurgical approach (thrombolysis or intensified anticoagulation) is usually successful. Patients should be instructed about heralding signs of valve thrombosis.
机械性三尖瓣人工瓣膜血栓形成是一种潜在的危险事件。本研究旨在探讨双叶瓣中三尖瓣血栓形成的发生率和临床表现，并评估其诊断和治疗方法。
在22例植入CarboMedics瓣膜的晚期存活患者中进行随访，随访期为36.0±20.8个月，以寻找三尖瓣血栓形成情况。瓣叶活动受限和/或可见血栓被视为瓣膜血栓形成的诊断依据。在5例患者中诊断出8次三尖瓣血栓形成事件（每100患者年12.1次）。3例患者抗凝不足，2例患者抗凝效果一般。3次发作出现明显的右心衰竭。常见的体格检查发现包括颈静脉搏动增强（5例患者）、舒张期三尖瓣杂音（4例患者）和外周水肿（4例患者）。所有病例均通过临床和经胸超声心动图怀疑诊断，并通过荧光透视和/或经食管超声心动图确诊。4例患者的两个瓣叶均受累。未见血栓显影。3例患者在4次发作中接受了溶栓治疗（3次完全成功，1次部分成功），无出血或栓塞并发症。1例患者对抗凝治疗有效。1例患者需要紧急再次手术。1例患者瓣膜血栓形成复发3次。
在抗凝效果一般或较差的患者中，三尖瓣位置的双叶瓣与瓣膜血栓形成的高发生率相关。铰链卡压仅需少量血栓物质。瓣膜血栓形成可能无症状。通常需要两个瓣叶均受累才会出现症状。非手术方法（溶栓或强化抗凝）通常成功。应指导患者了解瓣膜血栓形成的先兆体征。
