Role of cine-fluoroscopy, transthoracic, and transesophageal echocardiography in patients with suspected prosthetic heart valve thrombosis

Prosthetic heart valve thrombosis (PVT) is a rare but potentially life-thre atening complication of heart valve replacement. An effective, quick, and e asy diagnostic method is highly desirable. We evaluated the diagnostic effi cacy of cine-fluoroscopy (CF), transthoracic (TTE), and transesophageal (TE E) echocardiography in 82 consecutive patients with mechanical valves and s uspected PVT. Criteria for PVT were: leaflet(s) motion restriction at CF, i ncreased Doppler gradients at TTE, and evidence of thrombi at. TEE. Patient s were divided in 4 groups (A, B, C, and D) according to results of CF and TIE. Group A was composed of 24 patients with positive CF and TTE. Thrombi were detected by TEE in all cases, suggesting that when both are positive, CF and TTE correctly identified PVT in all patients so that TEE may be defe rred. Group B was composed of 12 patients with positive CF and negative TTE ; TEE showed PVT in 4 patients (33%). These patients had very slight leafle t motion restriction as in the case of initial PVT. This suggests that CF c ompared with Doppler may identify patients with "hemodynamically significan t" PVT,The remaining 8 patients in this group had monocuspid prostheses wit h negative TEE, suggesting that abnormal leaflet motion at CF may be due to functional changes. Therefore, TEE should always be performed in case of m onocuspid prostheses with isolated CF abnormalities. Group C was composed o f 18 asymptomatic patients with small-sized aortic prostheses and very high Doppler gradients on routine TIE, CF showed normal leaflet motion and TEE ruled out PVT in all cases outlining the diagnostic role of CF in this part icular subset. Finally, group D was composed of 28 patients with negative C F and TTE, TEE did not show thrombi in 24 of 28 patients (86%), confirming that, when both yield negative results, CF and TTE are reliable methods to rule out valve thrombosis in most cases. However, in 4 of 28 patients (14%) TEE showed "non-obstructive" prosthetic thrombosis: these patients herd mi tral prostheses, chronic atrial fibrillation, and 3 of 4 had systemic embol isms. Thus, TEE should be performed in selected patients despite negative C F and TTE results. Sensitivity, specificity, and positive and negative pred ictive values were 87%, 78%, 80%, and 91% for CF and 75%, 64%, 57%, and 78% far TIE, respectively. CF and TTE correctly identified PVT in 70 of 82 pat ients (85%). TEE was actually required in 15% of the cases. Thus, CF and TT E are quick, effective, and complementary diagnostic tools to diagnose PVT in most patients. TEE still remains the gold standard technique in selected cases. (C) 2000 by Excerpta Medica, Inc.