Thrombosis of bileaflet tricuspid valve prosthesis: Clinical spectrum and the role of nonsurgical treatment

Background Thrombosis of a mechanical tricuspid valve prosthesis is a poten tially hazardous event. This study aimed to explore the incidence and the c linical presentation of tricuspid valve thrombosis occurring in bileaflet v alves and to evaluate the diagnostic and the therapeutic approach. Methods and Results Tricuspid valve thrombosis was sought in 22 late surviv ors with the CarboMedics valve in a Follow-up period of 36.0 +/- 20.8 month s, limited leaflet motion and/or a visible thrombus were considered diagnos tic of valve thrombosis. Eight episodes of tricuspid valve thrombosis were diagnosed among 5 patients (12.1 episodes per 100 patient-years). Anticoagu lation was inadequate in 3 patients and fair in 2. Florid right heart failu re occurred in 3 episodes. Common physical findings included increased jugu lar venous pulse (5 patients), diastolic tricuspid murmur (4 patients), and peripheral edema (4 patients). The diagnosis was suspected in all clinical ly and by transthoracic echocardiography and confirmed by fluoroscopy and/o r transesophageal echocardiography. In 4 patients, both leaflets were invol ved. No thrombi were visualized. Three patients received thrombolytic thera py in 4 episodes (complete success in 3, partial success in 1) without hemo rrhagic or embolic complications. One patient responded to aggressive antic oagulant therapy. One patient required on emergent repeat surgery. In 1 pat ient, valve thrombosis recurred thrice. Conclusions In patients with fair or poor anticoagulation, a bileaflet valv e in the tricuspid position is associated with a high incidence of valve th rombosis. Hinge entrapment requires only a small amount of thrombotic mater ial. Valve thrombosis may be asymptomatic. Involvement of both leaflets is usually required to produce symptoms. A nonsurgical approach (thrombolysis or intensified anticoagulation) is usually successful. Patients should be i nstructed about heralding signs of valve thrombosis.