Transesophageal Echocardiography for the Diagnosis and Management of Nonobstructive Thrombosis of Mechanical Mitral Valve Prosthesis

Abstract

Diagnosis of a mechanical mitral valve prosthesis thrombosis is currently made with transthoracic Doppler echocardiography and occasionally with fluoroscopy. However, identifying a thrombus on a valve prosthesis may be difficult, especially if the thrombus is nonobstructive. To prospectively define the role of transesophageal echocardiography for identification of nonobstructive thrombi, we studied a series of patients in whom the prosthetic valve was considered to function normally on clinical examination and transthoracic echocardiography. One hundred fourteen consecutive patients with mechanical mitral valve prosthesis were investigated by both transthoracic echocardiography and transesophageal echocardiography. These examinations were performed for recent systemic emboli (15 patients), fever of unknown etiology (11 patients), routine postoperative evaluation (56 patients), and other reasons (32 patients). Based on transthoracic echo diagnosis, all prostheses were considered normal. Yet, in 20 patients transesophageal echocardiography revealed the presence of a 2- to 15-mm-long mobile thrombus localized on the atrial surface of the prosthesis. When compared with the remaining 94 patients with no visible thrombi, there was no significant difference between the two groups in terms of incidence of atrial fibrillation (65% versus 52%), left atrial size (48 +/- 9 versus 51 +/- 13 mm), left ventricular end-diastolic diameter (49 +/- 10 versus 51 +/- 13 mm) and fractional shortening (28 +/- 9% versus 31 +/- 10%), presence of spontaneous contrast to the left atrium (40% versus 41%), transprosthetic mean pressure gradient (4.0 +/- 1.4 versus 3.9 +/- 1.5 mm Hg), or the type of prosthesis used. After we discovered a nonobstructive thrombosis, patients were treated with heparin (n = 9) or oral anticoagulation (n = 11). The presence of a localized thrombus was confirmed in 3 patients who were operated on. In the present study, evolution appeared to depend on thrombus size: of 14 patients exhibiting a small (< 5 mm) thrombus, 10 had an uneventful course, whereas 5 of 6 patients with a large (> or = 5 mm) thrombus developed complications or died. Transesophageal echocardiography appears to be a reliable method to diagnose thrombi on a mechanical mitral valve prosthesis, even when transthoracic Doppler echocardiographic parameters appear to be normal. Transesophageal echo assessment of thrombus size may be helpful in deciding whether a patient with mitral prosthesis should be treated by anticoagulation, thrombolysis, or valve rereplacement.