JACC: Cardiovascular Imaging
Early Prosthetic Valve Dysfunction Due to Bioprosthetic Valve ThrombosisThe Role of Echocardiography
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Author + information
- Alexander Egbe, MBBSa,
- Sorin V. Pislaru, MD, PhDa,∗ (pislaru.sorin{at}mayo.edu),
- Mahmoud A. Ali, MB, BCha,
- Arooj R. Khan, MBBSa,
- Amber N. Boler, MDa,
- Hartzell V. Schaff, MDb,
- Emmanuel Akintoye, MD, MPHc,
- Heidi M. Connolly, MDa,
- Vuyisile T. Nkomo, MDa and
- Patricia A. Pellikka, MDa
- aDepartment of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
- bDepartment of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
- cDepartment of Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, Michigan
- ↵∗Address for correspondence:
Dr. Sorin V. Pislaru, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905.
Graphical abstract
Abstract
Objectives The purpose of this study was to review the institutional practice of surveillance transthoracic echocardiography (TTE) for diagnosing early prosthetic valve dysfunction (PVD).
Background Bioprosthetic valve thrombosis (BPVT) is an important cause of PVD, and guidelines do not recommend routine TTE during the first 5 years after valve implantation.
Methods The authors performed a retrospective case-control study of all suspected (imaging diagnosis) or confirmed (histopathological diagnosis) cases of BPVT from January 1997 through December 2016. Patients were matched 1:2 (age, sex, prosthesis position) to patients whose prostheses were explanted because of structural failure (SF). PVD was defined as a 50% increase above baseline gradient at valve implantation and classified as early (≤5 years) or late (>5 years) after implantation.
Results There were 94 BPVT (51 suspected, 43 confirmed) and 188 SF cases; patient age 61 ± 9 years; men 61 (65%). The prosthesis positions were aortic 56%; mitral 26%; tricuspid 15%; and pulmonary 3%. Early PVD was more common in the BPVT versus SF group: 83 of 94 (88%) versus 20 of 188 (11%) (p < 0.001). Time from implantation to PVD was shorter for BPVT than SF: 26 months (interquartile range [IQR]: 12 to 43 months) versus 74 months (IQR: 48 to 102 months) (p < 0.001). At the initial PVD diagnosis, 81% of BPVT and 90% of SF patients were asymptomatic. However, BPVT patients had rapid symptomatic deterioration, requiring intervention sooner after PVD diagnosis: 6 months (IQR: 4 to 7 months) versus 51 months (IQR: 22 to 55 months) (p < 0.001).
Conclusions Most patients with PVD due to BPVT were asymptomatic at initial diagnosis, which was made based on routine surveillance TTE, often performed before 5 years. BPVT, an acute disease process, requires timely diagnosis because patient conditions rapidly deteriorate. Further studies are needed to determine whether routine surveillance TTE should be considered for patients with bioprosthetic valves to identify pre-symptomatic features of BPVT in order to provide effective, appropriate therapy.
Footnotes
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 19, 2017.
- Revision received June 27, 2017.
- Accepted June 28, 2017.
- 2018 American College of Cardiology Foundation
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