Late thrombosis of the Björk-Shiley tilting disc valve in the tricuspid position: Thrombolytic treatment with streptokinase

Abstract

The main complication after implantation of a Björk-Shiley tilting disc valve in the tricuspid position is late thrombotic obstruction. Of 28 patients with tricuspid valve replacement (16 with mitral, aortic, and tricuspid valve replacement; 12 with mitral and tricuspid valve replacement), with a mean follow-up of 5.2 years, seven (25%) had thrombosis of the tricuspid prosthesis. Three patients had a recurrent thrombotic malfunction, for a total of ten thrombotic malfunctions in 146 patient-years, a rate of 6.8 per 100 patient-years. Thrombosis occurred late in all patients. Clinical deterioration presented with signs of congestive heart failure. In all patients the click of the tricuspid prosthesis was not audible and new diastolic or systolic murmurs were. The diagnosis was confirmed with cineradiography and bidimensional echocardiography (immobile disc, diminished opening angle of the disc). Thrombolytic treatment with streptokinase was used in all seven patients. Two patients required 12 hours of therapy and five patients, 24 hours. Thrombolytic treatment was monitored by the thrombin time. Complete regression of clinical, cineradiographic, and echocardiographic signs fo thrombosis was seen in all seven patients during the first 24 hours of therapy. There were no bleeding complications. In one patient clinical signs of mild pulmonary embolism occurred and were confirmed with chest radiographs. Follow-up, after successful treatment, extends from 4 to 30 months (mean 16.5 months). In four patients long-term results are excellent: There have been no clinical, cineradiographic, or echocardiographic signs of rethrombosis of the tricuspid prosthesis during the follow-up. Rethrombosis of the tricuspid prosthesis was observed in three patients 4, 7, and 14 months after initial treatment with streptokinase. Repeat thrombolytic treatment with streptokinase was successful in all three of these patients. Our experience with streptokinase treatment of thrombosis of tricuspid Björk-Shiley prostheses indicates that this form of treatment should always be applied before surgical intervention.