The use of transesophageal echocardiography guidance of thrombolytic therapy in prosthetic mitral valve thrombosis

Background and aim of the study: The aim of the study was to assess the use of transesophageal echocardiography (TEE) to guide thrombolytic therapy in prosthetic mitral valve thrombosis. Methods: Twenty-nine consecutive cases of prosthetic mitral valve thrombus diagnosed between January 1995 and May 1998 were managed according to data obtained by TEE. Three patients with pedunculated thrombus and five in NYHA functional classes I-II were referred for surgery. Patients who refused su rgery or who were in NYHA classes III-IV and had unpedunculated thrombus we re selected for thrombolytic therapy. Twenty-one patients (seven males, 14 females; mean age 47 +/- 8 years) received streptokinase for thrombolysis. Results: The mean period from valve replacement surgery was 36 +/- 23 month s, and mean time from onset of symptoms 9.2 +/- 14.3 days. Anticoagulant us e was inadequate in 18 (86%) patients. Fourteen cases (66%) were NYHA class IV, four (19%) in class III, and three (15%) in class II. Ten patients (48 %) were in atrial fibrillation. During the first 24 h of thrombolytic thera py, mean mitral valve peak and mean gradients fell from 25.6 +/- 4 and 13.8 +/- 2.5 mmHg to 11.7 +/- 5.3 and 7.1 +/- 3.1 mmHg respectively (p <0.0001) . Five cases with inadequate response to thrombolysis were treated for an a dditional 24 h. The mitral valve area increased from 1.0 +/- 0.1 cm(2) to 2 .3 +/- 0.7 cm2 after the first month (p <0.0001). Complete early success in thrombolysis was achieved in 17 (81%) cases, three cases (14%) had partial success, and one case (5%) was referred for surgery on the third day becau se of failed thrombolysis. Two minor skin bleedings (9%) not requiring tran sfusion were attributed to thrombolytic therapy. One case (5%) of successfu l thrombolysis had a non-fatal stroke after therapy and one (5%) was referr ed for surgery for recurrent prosthetic mitral valve thrombosis at six mont hs' follow up. None of the surgically treated patients died. Conclusion: Guidance of thrombolysis by TEE may reduce, but not eliminate, the risk of thromboembolic complications. Response to thrombolysis became a pparent within 24 h, but extending treatment beyond this time provided no a dditional short-term benefit.