ABSTRACT
BACKGROUND: Thrombotic occlusion of a prosthetic valve continues to be an uncommon but serious complication. Intravenous thrombolytic therapy has been proposed as an alternative to surgical treatment, but only in critically ill patients. METHODS AND RESULTS: Forty-one consecutive patients presenting with 48 episodes of prosthetic valve thrombosis (44 mitral and 4 aortic) were treated with thrombolytic therapy under serial echocardiographic guidance. There were 14 male and 27 female patients. The anticoagulation status was inadequate in 89.6% of episodes. Atrial fibrillation was present in 47.9% of episodes. The prostheses involved in these episodes were tilting disc in 45, bileaflet in 2, and ball and cage type in 1. The Sorin prosthetic valve was the most commonly involved. The time interval between valve replacement and thrombosis ranged from 1 month to 108 months (mean 20.4+/-20.6 months). Patients were in New York Heart Association functional class III in 47.9% and in class II in 43.9% of episodes. Thrombolytic agents used were streptokinase and urokinase in 44 and 4 episodes, respectively. The mean duration of thrombolytic therapy was 27.9+/-15.0 hours and the overall success rate was 87.5%. Patients developed peripheral embolism with almost complete recovery in 5 episodes while significant bleeding that required termination of thrombolytic therapy was observed in 2 episodes. Redo valve replacement was done in 3 episodes because these patients did not improve on thrombolytic therapy (all 3 cases were of recurrent prosthetic valve thrombosis and were found to have pannus peroperatively). Three patients died during thrombolytic therapy because of persistent heart failure. Six patients experienced a total of 13 epidoses of recurrent prosthetic valve thrombosis including index episodes (rethrombosis in 5, re-rethrombosis in 1). They were treated with repeated thrombolysis with a success rate of 76.92%. The mean duration of thrombolytic therapy in these episodes was 36.1+/-14.0 hours. CONCLUSIONS: In patients with prosthetic valve thrombosis, intravenous thrombolysis guided by echocardiography is a safe and effective method that may expand the indications for nonsurgical treatment of prosthetic valve thrombosis. By using serial echocardiography, the duration of thrombolytic therapy can be tailored to the patient's requirement for normalization of valve hemodynamics.
Subject(s)
Adolescent , Adult , Coronary Thrombosis/drug therapy , Echocardiography, Doppler , Female , Graft Occlusion, Vascular/drug therapy , Heart Valve Prosthesis , Humans , Male , Middle Aged , Plasminogen Activators/therapeutic use , Prosthesis Failure , Streptokinase/therapeutic use , Thrombolytic Therapy , Urokinase-Type Plasminogen Activator/therapeutic useABSTRACT
La hemodiálisis, uno de los tratamientos supletorios de la insuficiencia renal crónica, implica la depuración sanguínea periódica, a través de un acceso vascular (AV). La principal complicación de los AV son la estenosis y la obstrucción. El objetivo del presente trabajo es presentar nuestra experiencia en el tratamiento percutáneo de las disfunciones de los AV. Entre enero de 1993 y julio de 1995, se trataron por angioplastia (ATP), trombolisis (T-LIS) y trongoaspiración (T-ASP), 34 pacientes con insuficiencia en sus AV para hemodiálisis crónica. De éstos, 19 eran portadores de estenosis y 15 con oclusión del AV. El tratamiento percutáneo de las disfunciones de los AV es el procedimiento de elección ya que ofrece muy buenos resultados. Realizado precozmente, en etapa de estenosis, ofrece mejores resultados que aquellos con oclusión, mejorando significativamente su sobrevida
Subject(s)
Humans , Male , Female , Adult , Anastomosis, Surgical/adverse effects , Angioplasty, Balloon/methods , Capillary Permeability , Renal Dialysis/statistics & numerical data , Graft Occlusion, Vascular/surgery , Thrombolytic Therapy/methods , Thrombosis/therapy , Anastomosis, Surgical/rehabilitation , Angioplasty, Balloon/adverse effects , Chronic Disease/therapy , Renal Insufficiency, Chronic/surgery , Graft Occlusion, Vascular/drug therapy , Graft Occlusion, Vascular/therapyABSTRACT
Se trataron por angioplastia percutánea transluminal, trombolisis y/o tromboaspiración, veinticinco pacientes con insuficiencia en sus accesos vasculares para hemodiálisis crónica. Fueron éxitos iniciales 11 (85 por ciento) de 13 pacientes portadores de estenosis y 6 (50 por ciento) de 12 portadores de oclusiones del acceso vascular. En tres pacientes (3 oclusiones) se produjo reestenosis del acceso vascular requiriendo un segundo procedimiento de revascularización por angioplastia en un plazo medio de 4 meses (rango 2 - 8 meses). En los 13 pacientes portadores de estenosis la tasa de permeabilidad fue de 75 por ciento a los 6 meses, de 75 por ciento al año y del 75 por ciento a los 2 años. En los 12 pacientes portadores de oclusiones las tasas de permeabilidad fueron de 42 por ciento, 15 por ciento y 15 por ciento respectivamente. El tratamiento de las estenosis de accesos vasculares es el procedimiento de elección, realizándolo precozmente previene la oclusión del mismo mejorando significativamente su sobrevida