Kardiologie up2date 2008; 4(2): 185-194
DOI: 10.1055/s-2008-1077310
Kardiovaskuläre Notfälle

© Georg Thieme Verlag KG Stuttgart · New York

Thrombosen künstlicher Herzklappen

Meike  Schwarz, Constantin von  zur Mühlen, Christoph  Bode
Further Information

Publication History

Publication Date:
06 June 2008 (online)

Abstract

Thrombosis of prosthetic valves is the most threatening complication in patients after valve replacement. Due to the high morbidity and mortality of this event rapid diagnostic evaluation is crucial for the prognosis. The diagnosis is mainly based on auscultation, TTE and TEE. These methods also allow the thrombus size and the presence of outflow obstruction to be measured, which is essential for the further therapeutic decision. Moreover, the location (left versus right heart) and the clinical presentation (NYHA I-IV) need to be taken into account. The available therapeutic options are conservative therapy, surgery, and thrombolysis. This CME-article allows the reader to obtain the necessary knowledge about diagnostic and therapeutic pathways for patients with suspected prosthetic valve thrombosis.

Kernaussagen

  • Klinik: Die Symptome können plötzlich oder schleichend auftreten. Vom kardiogenen Schock über Synkope bis hin zur Herzinsuffizienz oder zu Thromboembolien kann das klinische Bild sehr unterschiedlich sein.

  • Auskultation: Charakteristisch ist der fehlende Klick. Herzgeräusche können auftreten.

  • Labor: D-Dimere, Entzündungswerte, Hämolysezeichen und Gerinnung sollten bestimmt werden.

  • Echokardiografie: In der TTE kann der transvalvuläre Gradient, in der TEE können Thrombusgröße und Klappenmobilität bestimmt werden.

  • Therapie: Bei nicht obstruierenden Thrombosen wird konservativ, bei obstruierenden linksventrikulären und insbesondere großen Thromben operativ vorgegangen. Bei rechtsventrikulären Thrombosen oder wenn eine OP unmöglich ist, ist eine Thrombolyse indiziert.

Literatur

  • 1 Roudaut R, Serri K, Lafitte S. Thrombosis of prosthetic heart valves: diagnosis and therapeutic considerations.  Heart. 2007;  93 137-142
  • 2 Bonow R O, Carabello B A, Kanu C. et al . ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons.  Circulation. 2006;  114 84-231
  • 3 Gencbay M, Turan F, Degertekin M, Eksi N, Mutlu B, Unalp A. High prevalence of hypercoagulable states in patients with recurrent thrombosis of mechanical heart valves.  J Heart Valve Dis. 1998;  7 601-609
  • 4 Gohlke-Barwolf C. Anticoagulation in valvar heart disease: new aspects and management during non-cardiac surgery.  Heart. 2000;  84 567-572
  • 5 Stein P D, Alpert J S, Dalen J E, Horstkotte D, Turpie A G. Antithrombotic therapy in patients with mechanical and biological prosthetic heart valves.  Chest. 1998;  114 (5 Suppl) 602S-610S
  • 6 Hirsh J, Dalen J, Anderson D R, Poller L, Bussey H, Ansell J, Deykin D. Oral anticoagulants: mechanism of action, clinical effectiveness, and optimal therapeutic range.  Chest. 2001;  119 (1 Suppl) 8S-21S
  • 7 Hirsh J, O'Donnell M, Eikelboom J W. Beyond unfractionated heparin and warfarin: current and future advances.  Circulation. 2007;  116 552-560
  • 8 Shapiro S S. Treating thrombosis in the 21st century.  N Engl J Med. 2003;  349 1762-1764
  • 9 Fritzsche D, Eitz T, Horstkotte D, Korfer R. Home monitoring of patients after prosthetic valve replacement. Early detection of valve dysfunction.  Herz. 2007;  32 491-498
  • 10 Shapira Y, Sagie A, Jortner R, Adler Y, Hirsch R. Thrombosis of bileaflet tricuspid valve prosthesis: clinical spectrum and the role of nonsurgical treatment.  Am Heart J. 1999;  137 (4 Pt 1) 721-725
  • 11 Heras M, Chesebro J H, Fuster V. et al . High risk of thromboemboli early after bioprosthetic cardiac valve replacement.  J Am Coll Cardiol. 1995;  25 1111-1119
  • 12 Deviri E, Sareli P, Wisenbaugh T, Cronje S L. Obstruction of mechanical heart valve prostheses: clinical aspects and surgical management.  J Am Coll Cardiol. 1991;  17 646-650
  • 13 Habib G, Cornen A, Mesana T, Monties J R, Djiane P, Luccioni R. Diagnosis of prosthetic heart valve thrombosis. The respective values of transthoracic and transoesophageal Doppler echocardiography.  Eur Heart J. 1993;  14 447-455
  • 14 Montorsi P, de Bernardi F, Muratori M, Cavoretto D, Pepi M. Role of cine-fluoroscopy, transthoracic, and transesophageal echocardiography in patients with suspected prosthetic heart valve thrombosis.  Am J Cardiol. 2000;  85 58-64
  • 15 Dzavik V, Cohen G, Chan K L. Role of transesophageal echocardiography in the diagnosis and management of prosthetic valve thrombosis.  J Am Coll Cardiol. 1991;  18 1829-1833
  • 16 Gueret P, Vignon P, Fournier P, Chabernaud J M, Gomez M, LaCroix P, Bensaid J. Transesophageal echocardiography for the diagnosis and management of nonobstructive thrombosis of mechanical mitral valve prosthesis.  Circulation. 1995;  91 103-110
  • 17 Tong A T, Roudaut R, Ozkan M. et al . Transesophageal echocardiography improves risk assessment of thrombolysis of prosthetic valve thrombosis: results of the international PRO-TEE registry.  J Am Coll Cardiol. 2004;  43 77-84
  • 18 Alpert J S. The thrombosed prosthetic valve: current recommendations based on evidence from the literature.  J Am Coll Cardiol. 2003;  41 659-660
  • 19 Lengyel M, Vandor L. The role of thrombolysis in the management of left-sided prosthetic valve thrombosis: a study of 85 cases diagnosed by transesophageal echocardiography.  J Heart Valve Dis. 2001;  10 636-649
  • 20 Roudaut R, Lafitte S, Roudaut M F. et al . Fibrinolysis of mechanical prosthetic valve thrombosis: a single-center study of 127 cases.  J Am Coll Cardiol. 2003;  41 653-658
  • 21 Roudaut R, Roques X, Lafitte S, Choukroun E, Laborde N, Madona F, Deville C, Baudet E. Surgery for prosthetic valve obstruction. A single center study of 136 patients.  Eur J Cardiothorac Surg. 2003;  24 868-872
  • 22 Das M, Twomey D, Al K haddour, Dunning J. Is thrombolysis or surgery the best option for acute prosthetic valve thrombosis?.  Interact Cardiovasc Thorac Surg. 2007;  6 806-811

Dr. med. Meike Schwarz

Universitätsklinikum Freiburg

Abteilung für Kardiologie und Angiologie

Hugstetterstr. 55

79106 Freiburg

Email: schwarz@med1.ukl.uni-freiburg.de