Surgery For Prosthetic Valve Obstruction May Currently Be Safest, Most Effective Treatment

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Early operation is appears effective and safe for most cases of prosthetic heart valve obstruction (PHVO), especially in patients in stable preoperative haemodynamic condition, according to a French study.

Valve obstruction due to prosthetic thrombosis is one of the most serious complications associated with mechanical prosthetic valves. Surgery is usually the favoured treatment, although reported mortality rates are high, depending on patient clinical status.

To better define the efficacy and safety of surgery, Raymond Roudaut, MD, and colleagues of Hopital Cardiologique du Haut-Leveque, Pessac, France, performed a single-centre retrospective study of all cases of surgery for prosthetic heart valve thrombosis (PHVT).

The researchers identified a total of 136 PHVO episodes that were treated with surgery. Among the patients, 63.3% were women and 36.7% were men, with an overall mean age of 59 years. The mean delay between implantation and thrombotic episodes was 7.4 years.

PHVO was diagnosed mainly by fluoroscopy and/or echocardiography assessment. Thrombosed valves included bileaflet (60%), tilting disc (35%) and ball cage (5%), with the thrombosis being obstructive in 89% of cases. At the time of PHVT, management of anticoagulant therapy was inadequate according to international standards in 52% of patients.

Surgery was indicated in 99 patients as the first step of therapy, and in 37 patients as a secondary treatment due to incomplete results of either fibrinolysis or heparin therapy. Operative procedures included valve re-replacement (104 cases) using a mechanical or bioprosthetic valve, and declotting-pannus excision (32 cases).

Of the patients, 10.3% died within 30 days of surgery due to low cardiac output syndrome. Notably, the operative mortality rate was significantly higher in patients who were in functional class IV at the time of surgery.

Surgery was successful in 89% of patients. However, prosthetic heart valve thrombosis recurred in 8.1% of survivors during a mean follow up of 3.15 years.

“Our study shows that surgery remains a high-risk option particularly in patients in functional class IV, but appears currently safer,” conclude the researchers. “Declotting alone cannot be recommended because of a higher thrombosis recurrence.”

Eur J Cardiothorac Surg 2003 Dec;24:6:868-72.