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Prosthetic valve thrombosis: is it time for a new consensus conference?

After cardiac valve replacement, complications may occur due to structural deterioration of the prosthesis and nonstructural dysfunction including infection, embolism, thrombosis, and others. The prosthetic heart valve thrombosis (PVT) used to be a very serious complication in this type of patients; however, it may be an incidental finding during an echocardiografic test. Kaya et al. 1 report a new case to the medical literature, particularly interesting, because the patient is a 82-year-old woman who was admitted in NYHA IV functional class, a frequent form of presentation, and with inadequate anticoagulation level. In this patient, the diagnosis has been done using transthoracic echocardiography (TTE). The first choice of treatment was the surgery, but the patient refused due to her clinical status. The thrombolysis with streptokinase was effective. Transthoracic echocardiography is the diagnostic tool often used to evaluate a patient with valve prosthesis, when there is suspicion of PVT, and also is useful in the follow-up of patients during thrombolysis. The transesophageal echocardiography shows images with more resolution, and also has high sensibility to identify abnormal mass. It can be useful for differentiating thrombus and pannus. A study demonstrated that the probability of thrombosis is higher in patients with two or more predictors (INR � 2.5, abnormal mass at an oclusor, elevated gradients and mobile mass). 2 This difference is really important to begin the thrombolysis treatment. The therapeutic decision in patients with PVT is controversial yet. The guidelines for management of left-sided PVT in 1997 proposed that surgery treatment should be the preferred therapeutic modality for most patients with PVT. Thrombolysis, followed by heparin, warfarin, and aspirin, is advised for high-risk surgical candidates. 3 This therapeutic decision was based fundamentally on the occurrence of embolism.