Roudaut R, Labbe T, Lorient-Roudaut M F, Gosse P, Baudet E, Fontan F, Besse P, Dallocchio M
Cardiologic Hospital of Bordeaux, France.
Circulation. 1992 Nov;86(5 Suppl):II8-15.
Thrombosis is a serious complication of heart valve replacement, and management is often difficult. In recent years, thrombolytic therapy has been used as the primary technique by some investigators.
Sixty-four consecutive patients presenting with 75 instances of prosthetic heart valve thrombosis (41 mitral, 33 aortic, one tricuspid) were treated with fibrinolytic agents. Obstructed prosthetic valves comprised 39 tilting disc and 36 bileaflet valves. The time interval between valve replacement and obstruction ranged from 15 days to 192 months (mean, 38 months). Fibrinolytic agents used were streptokinase (42 patients), urokinase (27 patients), or recombinant tissue-type plasminogen activator (six patients). Immediate results of fibrinolytic treatment were 1) full success after one or several consecutive fibrinolytic regimens in 55 cases (73%), 2) incomplete improvement in two cases, and 3) failure in 18 cases, leading to an emergency surgery in nine cases. Nine patients died (four strokes, four cardiac arrests, one hemorrhage). Only one severe hemorrhagic complication was observed, but 11 cases of embolism occurred during fibrinolytic treatment (14.6%) (four major cerebral embolisms with death). The immediate efficacy was better for thrombosed aortic prosthesis than with the mitral prosthesis (85% versus 63%).
Fibrinolytic treatment appears to be an attractive nonsurgical alternative for prosthetic heart valve thrombosis, but because of the risk of cerebral embolism, its use should be reserved for tricuspid valve thrombosis or critically ill patients with mitral or aortic valve thrombosis. The use of a fibrinolytic agent in cases of small, nonobstructive paravalvular thrombosis demonstrated with transesophageal echocardiography needs further studies.
血栓形成是心脏瓣膜置换术的一种严重并发症，其治疗往往困难重重。近年来，一些研究人员将溶栓治疗作为主要技术手段。
连续64例出现75次人工心脏瓣膜血栓形成（41例二尖瓣、33例主动脉瓣、1例三尖瓣）的患者接受了纤维蛋白溶解剂治疗。阻塞的人工瓣膜包括39个倾斜碟瓣和36个双叶瓣。瓣膜置换与阻塞之间的时间间隔为15天至192个月（平均38个月）。使用的纤维蛋白溶解剂有链激酶（42例患者）、尿激酶（27例患者）或重组组织型纤溶酶原激活剂（6例患者）。溶栓治疗的即刻结果为：1）55例（73%）在接受一次或几次连续溶栓方案后完全成功；2）2例改善不完全；3）18例失败，其中9例导致急诊手术。9例患者死亡（4例中风、4例心脏骤停、1例出血）。仅观察到1例严重出血并发症，但在溶栓治疗期间发生了11例栓塞（14.6%）（4例严重脑栓塞伴死亡）。血栓形成的主动脉人工瓣膜的即刻疗效优于二尖瓣人工瓣膜（85%对63%）。
溶栓治疗似乎是人工心脏瓣膜血栓形成一种有吸引力的非手术替代方法，但由于存在脑栓塞风险，其应用应仅限于三尖瓣血栓形成或患有二尖瓣或主动脉瓣血栓形成的重症患者。对于经食管超声心动图显示的小的、非阻塞性瓣周血栓形成病例，使用纤维蛋白溶解剂需要进一步研究。
