1
APPENDIX
TABLE A. Obstructive prosthetic heart valve thrombosis treated with thrombolysis:
17 studies comprising 756 patients
Mean age
(years)
32.5
NYHA
class
I/II
82
NYHA
class
III/IV
37
CVA or
emboli
6
major
bleeding
11
Mean 4.3
years
5
5
2
# patients
120
lytics used
SK
Valve
79M/30A
/11AM
Aoyagi et al
(7) †
10
UK
2M/4A/4
T
Vitale et al
(8)
15
rtPA
15M
Manteiga
et al (9)
19
rtPA, SK
14M/2A/
3T/3P
49
15F/4M
Mean 6
years
7
Gupta et al
(10)
110
SK, UK
96M/14A
(17MA)
35.4
58F/52M
Mean 2
years
Lengyel et
al (11)
32
SK, UK,
rtPA
30M/2A
56
18F/14M
Lopez et al
(12)
15
SK
10M/3A/
2T
36
11F/4M
Range 3
months
to 21
years
Mean 5.2
years
Teshima et
al (13) *
22
rt-PA,
monteplase
, UK
1M/18A/
1T/2RVO
T conduit
54
15F/7M
Ramos et al
(14)
17
SK
16
(7M/6A/3
T) + 1
porcine
41
Roudaut et
al (15)
110
SK, UK, rtPA
79M/46A
/1T/1MT
57
Durrleman
et al (16)
6
SK, rtPA
N/A
Renzulli et
al (17)
26
rtPA
N/A
Tong et al
(18)
107
SK, UK, tPA
79M/13A
/15T
(1porcine
)
54.2
71F/36M
Median
33 days
39
68
17
Balasundar
am et al
(19)
51
SK, UK
N/A
N/A
N/A
N//A
N/A
N/A
CaceresLoriga et al
(20)
68
rSK
50M/9A/
9T
40.4
53F/15M
Mean 6.8
years
4
Ermis et al
(21)
15
SK
11M/2A/
2T
51.3
8F/7M
Mean 5.5
years
Keuleers et
al (22)
13
rtPA
8M(incl 1
bio)/2A/3
T
61
Median
11 years
Karthikeyan
et al (6)
42.2
gender
53F/67M
Time
since
implant
Mean 2.1
years
IMAGING
MODALITY
Fluoroscopy,
TTE
CLINICAL
PRESENTATION
dyspnea, angina,
heart failure
with or without
muffled heart
sounds on
auscultation
in 20 total
patients:16 with
new murmur, 4
with abnormal
opening or
closing sound of
prosthetic valve
dyspnea, loss of
valve clicks
Outcome
61 of 82 Class
I/II with CS; 9
of 37 Class
III/IV with CS
deaths
9
recurrence
N/A
0
4 CS, 1PS, 5I
2
1 of 5 after
initial
successful
thrombolysi
s
Fluoroscopy,
TTE, TEE
4
0
14 CS, 1I
0
N/A
TEE
15
3
0
13CS, 5 PS, 1I
1
3
Fluoroscopy,
TTE, TEE
25
78 class
III/IV, 7
class V
26
9
8
21
Fluoroscopy,
TTE,TEE
5
27
3
2
90CS, 11PS, 9
F (NYHA class
I/II CS 80%,
NYHA class III
CS 86%, NYHA
class IV/V CS
73.5%)
27 CS,3PS,2I
4
6
TTE,TEE
1
14
2
0
13CS, 1PS, 1 I
1
3
TTE,TEE
Mean 6.5
years
24
3
1
0
15 of 27 CS, 6
PS, 6 I
N/A
N/A
Fluoroscopy,
TTE
12F/29M
Mean 6
years for
A,
3.4 years
for M&T
N/A
N/A
4
1
Aortic: 3CS,
1PS,2I; MT:
8CS, 2PS, 1I
1
4
Fluoroscopy,
TEE
worsening of
physical capacity
and dyspnea
70F/40M
Mean 4.3
years
37
90
19
6
90 of 127 CS,
22 PS, 15 I
(NYHA I/II CS
81%; NYHA
III/IV CS 67%)
15
24
Fluoroscopy,
TTE, TEE
dyspnea, CHF,
systemic
embolism
48% with
inadequate
anticoagulat
ion
2CS/3I (1 to
OR while
receiving
lytics)
2
14CS
1
12
TTE,TEE
Dyspnea, CHF,
systemic
embolism
8
inadequate
4
71CS, 8PS
(hemodynami
c success class
I 92.9%, class
II 88%, class III
85.7%, class IV
84.2%)
6
9
TEE
33 with INR
>2.5
9
1
46 CS/17
PS/12 I
4
15% for 1st
episode;
64.7% for
recurrence
Fluoroscopy,
TTE
98 with
dyspnea, 3
shock, 6 angina,
1 cardiac arrest,
12 CVA, 5
peripheral
emboli, 5
asymptomatic
N/A
64
7
2
58CS/4 PS/6I
(NYHA class
IV:
29CS+3PS+4I;
class III:
25CS+1PS+2I;
class II: all CS)
4
11
TTE
17
adequate,
51
inadequate
2
13
2
2
12CS, 3I
2
1
Fluoroscopy,
TTE,TEE
recent onset of
dyspnea,
orthopnea,
and/or PND and
signs of
pulmonary
vascular
congestion,
associated with
absent
prosthetic valve
clicks
Dyspnea,
angina, CVA,
shock
4
9
4
1
8 CS, 4 PS, 1I
1
4
TTE
90% with
dyspnea, 13
(42%) in NYHA
IV, 2 with chest
pain, 4 with
systemic
embolic
episodes, 10
8
inadequate
7F/3M
N/A
5
18 CHF, 2
peripheral
embolism, 2
absence of
prosthetic
sounds
N/A
recent onset
dyspnea, cough,
pulmonary
venous
congestion,
diminution of
prosthetic valve
clicks
N/A
INR
N/A
5
inadequate,
5 adequate
12 of 87
with
inadequate
INR
68% with
suboptimal
levels 3
months
prior to
event
62
adequate,
31
inadequate
4
adequate,
28
inadequate
8
inadequate,
7 adequate
11
inadequate,
inadequate
anticoag
during
dental in 2,
antiphosph
olipid
antibody
syndrome
in 1
6 adequate,
11
inadequate
Fluoroscopy,
TTE, TEE
N/A
11 with INR
< 2.5
2
with diminished
heart sounds
*
†
2 patients with RVOT conduit secondary to double outlet RV
2 patients aged 2
A: Aortic valve
CHF: congestive heart failure
CS: Complete Success
CVA: Cerebrovascular accident
F: Female
I: Ineffective
M: Mitral valve
MA: Mitral and aortic valve
M: Male
MT: Mitral and tricuspid valve
N/A: Data not available
NYHA: New York Heart Association
P: Pulmonic valve
PS: Partial Success
rSK: Recombinant streptokinase
Rt-PA: Recombinant tissue plasminogen activator
RVOT: Right ventricular outflow tract
SK: Streptokinase
T: Tricuspid valve
TEE: Transesophageal echocardiography
TIA: Transient ischemic attack
tPA: Recombinant plasminogen activator
TTE: Transthoracic echocardiography
UK: Urokinase
3
TABLE B. Obstructive prosthetic heart valve thrombosis treated with surgery and valve
replacement: 13 studies comprising 662 patients
Mean
age
44
NYHA
class
I/II
2
NYHA
class
III/IV
8
CVA or
emboli
0
3
3
0
Peri-op
mortality
2 of 16
2M/1A/
3T
44,
pannus
27M/
13A/3
MA/
1MAT
Mean 13
years
3?
27,
thrombus
20M/3
A/ 2T/
1MA/
1MT
Mean 6.2
years
14
Bollag et
al (24)
13
11M/
2A
52
7F/6M
Mean 12.5
years
1
12
4 on
present
ation, 3
post-op
3
Lengyel
et al (11)
14
13M/1
A
51
12F/2M
Range 6
months to
14 years
2
12
4
4
TTE,TEE
Durrlema
n et al
(16)
28 + 4
(post
thrombol
ysis)
23M/
5A
3
3
Fluoroscopy,
TTE, TEE
22 with dyspnea, 5 with
shock, 5 with
auscultation changes
21 with
INR < 2.5
Of 38 patients: 13
fresh thrombus, 5 old
thrombus, 20 with
both characteristics
Renzulli
et al (17)
213
173M/
40A
2
27
TTE,TEE
Dyspnea, CHF, systemic
embolism
40 inadequate
78 thrombus, 93
pannus, 42 pannus and
thrombus
Ozkokeli
et al (25)
30
24 M/
6A
41
18F/12
M
Mean 7.58
years
5
25
6 on
present
ation
6
TTE,TEE
10% with "cardiac
insufficiency", 4 with
"cardiogenic shock or
pulmonary edema"
15 inadequate
25 thrombus, 5 pannus
Lafci et al
(26)
18
14M/
4A
35.9
12F/6M
Mean 4
years
2
16
1
3
fluoroscopy
TTE, TEE
13 with
INR <2
thrombus + pannus in
7, thrombus in 6,
pannus in 5
Toker et
al (27)
63
47M/6
A/
10MA
40.3
42F/21
M
Mean 4.9
years
11
13
N/A
N/A
28 inadequate
45 with pannus, 18
with thrombus
Ahn et al
(28)
20
14M/2
A/3T/
1TA
42
14F/6M
Mean 10.2
years
9
11
1
1
0
TTE,TEE
13/20 with CHF, 12 with
dyspnea
6
adequate
N/A
Roudaut
et al (29)
136
90M/
38A/
2T/5M
A/1MT
59
86F/50
M
Mean 7.4
years
15
85
1
14
10
fluoroscopy,
TTE, TEE
main signs: dyspnea,
CHF, or embolism
76%
inadequate
N/A
Ermis et
al (21)
18
13M/3
A/2T
53
12F/6M
Mean 6.2
years
5
13
1
3
N/A
Fluoroscopy,
TTE,TEE
Dyspnea, angina, CVA,
shock
12 with INR
<2.5
Keuleers
et al (22)
18
9M
55
N/A
Mean 10
years
2
7
0
0
2
TTE
90% with dyspnea, 13
(42%) in NYHA IV, 2 with
chest pain, 4 with
systemic embolic
episodes, 10 with
diminished heart sounds
4 inadequate
6A
66
N/A
Mean 13.5
years
0
6
0
2
0
3 inadequate
3T
44
N/A
Mean 11.5
years
2
1
0
0
0
0 inadequate
Rizzoli et
al (23)
Mean 3.24
years
A: Aortic valve
CS: Complete success
CVA: Cerebrovascular accident
CLINICAL PRESENTATION
11 with dyspnea, 2 with
syncope, 4
asymptomatic, 16 with
new murmur, 4 with abn
opening or closing sound
INR
9
adequate
N/A
only 1
with
major
deviation
from
anticoag,
6 with
"faulty
anticoagu
lation
control"
PANNUS VS
THROMBUS
thrombus alone or
with little pannus in
16, pannus with little
or no thrombus in 4
6 surgery
after
failed
lysis
36
Recurrence
0
IMAGING
MODALITY
Fluoroscopy,
TTE,TEE
Valve
3M/7A
Aoyagi et
al (7)
gender
8F/2M
time since
implant
Mean 4.3
years
# patients
10
0
N/A
44 pannus (25% had
thrombus too)
27 thrombus (2 with
pannus)
0
9
fluoroscopy
TTE, TEE
fluoroscopy
TTE,TEE
6 with emboli,
disappearance of clicks in
5, change in heart
murmur in 10
11 inadequate
11 with thrombus, 5
with thrombus +
pannus
20 surgical: 8 pannus,
11 thrombus, 1 pannus
and thrombus
for surgical arm (10
with thrombus only, 9
with thrombus and
pannus)
4
INR: International normalized ratio
M: Mitral valve
MA: Mitral and aortic valve
MAT: Mitral, aortic, and tricuspid valves
MT: Mitral and tricuspid valve
N/A: Data not available
NYHA: New York Heart Association
P: Pulmonic valve
T: Tricuspid valve
TIA: Transient ischemic attack
5
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