Kandpal Bhuwanesh, Garg Naveen, Anand K V, Kapoor Aditya, Sinha Nakul
Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, India.
J Heart Valve Dis. 2002 Jul;11(4):594-600.
Left atrial (LA) and/or left atrial appendage (LAA) thrombi are often found in patients with rheumatic mitral stenosis (MS). The fate of these thrombi on optimal oral anticoagulation, and the feasibility of balloon mitral valvulotomy (BMV) is not well established. The study aims were to assess the efficacy of oral anticoagulation in the resolution/organization of these thrombi, and the feasibility and safety of Inoue BMV in these patients.
All consecutive patients with severe MS and a mitral valve suitable for BMV, but found to have LA/LAA thrombus on transesophageal echocardiography (TEE) between January 1999 and January 2001 were included. Anticoagulation was carried out with oral nicoumalone; the INR was maintained at 2.5-3.5. Follow up TEE was performed at intervals of two months for a maximum of six months. BMV using the Inoue balloon technique was performed as soon as possible after resolution or organization of thrombus.
Sixty-six patients with MS (41 females, 25 males, mean age 33.1+/-10.4 years) and LA thrombus on TEE were studied. Thrombi were categorized into three groups: type I, thrombi localized to LAA (n = 36; 54.6%); type II, LAA thrombi protruding just beyond the LAA mouth (n = 22; 33.3%); and type III, LAA thrombi extending into the LA cavity (n = 8; 12.1%). Mean thrombus size was 27.6+/-9.1 mm (range: 15-35 mm). Complete resolution was seen in 22 patients (33.3%), and organization in 38 (57.6%). No significant change was observed in six patients (9.1%). Resolution was most common in the first two months, and in type I thrombi (41.7%, 27.2% and 12.5% in type I, II and III thrombi, respectively). BMV was performed in 90.9% of patients, and was uneventful in all. BMV was performed in the presence of organized thrombus in 63% of patients.
Anticoagulant therapy is effective in resolution and/or organization of LA thrombi in patients with MS. Six months' duration of anticoagulation appears optimal. BMV using the Inoue balloon technique can be performed safely after resolution or organization of thrombus, with no additional risk of complication.
风湿性二尖瓣狭窄（MS）患者常出现左心房（LA）和/或左心耳（LAA）血栓。这些血栓在最佳口服抗凝治疗下的转归以及球囊二尖瓣成形术（BMV）的可行性尚未明确。本研究旨在评估口服抗凝治疗对这些血栓溶解/机化的疗效，以及Inoue球囊二尖瓣成形术在这些患者中的可行性和安全性。
纳入1999年1月至2001年1月期间所有经食管超声心动图（TEE）检查发现患有严重MS且二尖瓣适合BMV但存在LA/LAA血栓的连续患者。采用口服尼可香豆素进行抗凝治疗，国际标准化比值（INR）维持在2.5 - 3.5。每两个月进行一次随访TEE，最长随访6个月。血栓溶解或机化后尽快采用Inoue球囊技术进行BMV。
对66例经TEE检查发现有MS且存在LA血栓的患者（41例女性，25例男性，平均年龄33.1±10.4岁）进行了研究。血栓分为三组：I型，局限于LAA的血栓（n = 36；54.6%）；II型，LAA血栓突出于LAA口外（n = 22；33.3%）；III型，LAA血栓延伸至LA腔（n = 8；12.1%）。平均血栓大小为27.6±9.1 mm（范围：15 - 35 mm）。22例患者（33.3%）血栓完全溶解，38例（57.6%）血栓机化。6例患者（9.1%）未见明显变化。血栓溶解在最初两个月最为常见，且在I型血栓中最为常见（I型、II型和III型血栓的溶解率分别为41.7%、27.2%和12.5%）。90.9%的患者接受了BMV，所有患者手术过程均顺利。63%的患者在存在机化血栓的情况下进行了BMV。
抗凝治疗对MS患者LA血栓的溶解和/或机化有效。抗凝治疗6个月似乎最为适宜。采用Inoue球囊技术的BMV在血栓溶解或机化后可安全进行，且无额外并发症风险。
