Lengyel M, Vandor L
Gottsegen Györgyi Hungarian Institute of Cardiology, Budapest, Hungary.
J Heart Valve Dis. 2001 Sep;10(5):636-49.
Treatment strategies of prosthetic valve thrombosis (PVT) are controversial. The aim of this study was to compare the efficacy and safety of thrombolysis, surgery and heparin therapy in patients with either obstructive or non-obstructive PVT.
Between 1993 and 2000, 85 episodes of PVT were found (82 in the mitral position, three in the aortic) in 59 patients (22 males, 37 females; mean age 53 years; range: 28-80 years) by multiplane transesophageal echocardiography (TEE). Obstructive PVT was defined as restricted leaflet (occluder) motion with increased gradient, even if thrombus was not seen by TEE; non-obstructive PVT was considered as normal leaflet motion, irrespective of the gradients. Thrombolysis was given in 43 episodes (streptokinase, n = 37) by standard dosage protocols, surgery was performed in 20, and i.v. heparin was used in 22. Recurrence rate was calculated in 26 survivors of successful thrombolysis based on six months to six years follow up. Treatment with thrombolysis and heparin was monitored using TEE.
There were 54 cases of obstructive PVT and 31 cases of non-obstructive PVT. Anticoagulation was inadequate in 82% of cases. Thrombolysis was completely successful in 37 cases (86% success rate); in 27 of 32 patients with obstructive PVT (in both cases of aortic location), and in 10 of 11 non-obstructive PVT. Heparin was successful in only nine of 18 non-obstructive PVT, and in none of four obstructive cases. Nine patients died, all with obstructive PVT, and all but one were in NYHA class IV; two were treated by thrombolysis (5% mortality), six by surgery (30% mortality) and one with heparin (5% mortality). Complications of thrombolysis included two strokes and two transient ischemic attack episodes (9%), and bleeding in one case (2%). There were six complications due to heparin treatment: newly developed obstruction in five patients and stroke in one patient. Recurrence was diagnosed in eight episodes in six patients with obstructive PVT after successful thrombolysis (22%); rethrombolysis was successful in four of five cases.
Thrombolysis was shown to be superior to surgery in obstructive PVT, especially in NYHA class IV patients. Severe complications of thrombolysis were noted only in the critically ill. As heparin treatment appeared ineffective and unsafe for the treatment of PVT, thrombolysis appeared to be the optimal therapeutic choice in this condition.
人工瓣膜血栓形成（PVT）的治疗策略存在争议。本研究旨在比较溶栓、手术及肝素治疗在梗阻性或非梗阻性PVT患者中的疗效与安全性。
1993年至2000年间，通过多平面经食管超声心动图（TEE）在59例患者（22例男性，37例女性；平均年龄53岁；范围：28 - 80岁）中发现85次PVT发作（二尖瓣位82次，主动脉瓣位3次）。梗阻性PVT定义为瓣叶（封堵器）活动受限且压差增加，即便TEE未发现血栓；非梗阻性PVT则视为瓣叶活动正常，无论压差情况。43次发作采用标准剂量方案给予溶栓治疗（链激酶，n = 37），20次进行了手术，22次使用静脉肝素治疗。基于6个月至6年的随访，对26例溶栓成功的幸存者计算复发率。使用TEE监测溶栓及肝素治疗情况。
梗阻性PVT 54例，非梗阻性PVT 31例。82%的病例抗凝不充分。溶栓完全成功37例（成功率86%）；32例梗阻性PVT中的27例（包括2例主动脉瓣位病例）以及11例非梗阻性PVT中的10例。肝素治疗仅在18例非梗阻性PVT中的9例成功，4例梗阻性病例均未成功。9例患者死亡，均为梗阻性PVT，除1例外在纽约心脏协会（NYHA）心功能分级均为IV级；2例接受溶栓治疗（死亡率5%），6例接受手术治疗（死亡率30%），1例接受肝素治疗（死亡率5%）。溶栓并发症包括2例中风和2次短暂性脑缺血发作（9%），1例出血（2%）。肝素治疗导致6例并发症：5例患者出现新的梗阻，1例患者发生中风。6例梗阻性PVT患者溶栓成功后有8次发作被诊断为复发（22%）；5例中的4例再次溶栓成功。
在梗阻性PVT中，溶栓治疗显示优于手术，尤其对于NYHA心功能IV级患者。仅在危重症患者中观察到溶栓的严重并发症。由于肝素治疗对PVT治疗似乎无效且不安全，溶栓似乎是这种情况下的最佳治疗选择。
