ABSTRACT
INTRODUÇÃO: O acometimento multivalvar é comumente encontrado no paciente reumático em idade precoce levando a várias intervenções cirúrgicas. O sucesso no tratamento via transcateter, possibilitou a abordagem destes pacientes de alto risco. DESCRIÇÃO DO CASO: Paciente masculino, 59 anos, acompanhado por 40 anos em hospital terciário, com múltiplas cirurgias valvares devido à febre reumática. Realizou troca valvar aórtica biológica em 1982, seguida de retroca aórtica por prótese mecânica e troca mitral por prótese mecânica em 1989. Houve trombose em ambas as próteses mecânicas levando à substituição por biopróteses em 1986. Em 2004, endocardite levou a retroca valvar mitral e aórtica por próteses biológicas. Evoluiu com fibrilação atrial em 2005. Ecocardiograma em 2010, apresentava função biventricular preservada, discreta hipertensão pulmonar e insuficiência tricúspide (IT) discreta à moderada, secundária ao remodelamento atrial com progressão para importante em 2016 (anel tricuspídeo de 45 mm). Evoluiu em 2023 com sintomas congestivos refratários ao tratamento clínico, na ocasião, diagnosticado com IT torrencial e disfunção estrutural de bioprótese aórtica do tipo insuficiência. Devido ao risco cirúrgico elevado após as 4 intervenções cirúrgicas prévias (17,9% EUROSCORE, 22% STS Score), foi contra-indicada a cirurgia e proposto procedimento percutâneo, com abordagem inicial na IT e posteriormente na valva aórtica. Em virtude da instabilidade clínica apresentada, procedeu-se à realização sequencial, durante a mesma internação, de intervenção percutânea por meio do Tric-Valve® e Valve-in-Valve aórtico, com êxito. No seguimento ambulatorial, após 1, 6 e 8 meses o paciente estava em classe funcional I (NYHA), sem necessidade de novas consultas ao Pronto-Socorro e em baixa dose de furosemida. CONCLUSÃO: A mortalidade intra-hospitalar com a associação de intervenção cirúrgica aórtica e tricúspide mostrou mortalidade de 13,2% na literatura, sem considerar o número de reoperações. O tratamento percutâneo com implante de stent nas veias cavas superior e inferior e o Valve-in-valve aórtico emergem como opção promissora para pacientes com alto risco cirúrgico, oferecendo melhorias significativas na sintomatologia e na qualidade de vida.
ABSTRACT
OBJECTIVE: To assess the short- and long-term results of the use of streptokinase (SK) for the treatment of thromboses in cardiac valvular prostheses. METHODS: Seventeen patients with cardiac prosthetic thrombosis diagnosed by clinical, echocardiographic, and radioscopic findings underwent fibrinolytic treatment with a streptokinase bolus of 250,000 U followed by 100.000 U/hour. Short- and long-term results were assessed by radioscopy and echocardiography. RESULTS: Of the 17 patients, 12 had mechanical double-disk prostheses (4 aortic, 6 mitral, 2 tricuspid), 4 had single-disk prostheses (2 aortic, 1 mitral, and 1 tricuspid), and 1 had a tricuspid bioprosthesis. The success rate was 64.8%, the partial success rate was 17.6%, and the nonsuccess rate was 17.6%. All patients with a double-disk prosthesis responded, completely or partially, to the treatment. None of the patients with a single-disk prosthesis had complete resolution of the thrombosis. The time of streptokinase infusion ranged from 6 to 80 hours (mean of 56 h). The mortality rate due to the use of streptokinase was 5.8% and was secondary to cerebral bleeding. During streptokinase infusion, 3 (17.6%) embolic episodes occurred as follows: 1 cerebral, 1 peripheral, and 1 coronary. The rethrombosis index was 33% in a mean follow-up of 42 months. CONCLUSION: The use of fibrinolytic agents was effective and relatively safe in patients with primary thrombosis of a double-disk prosthesis. A fatal hemorrhagic complication occurred in 1 (5.8%) patient, and embolic complications occurred in 3 (17.6%) patients. In a mean 42-month follow-up, 67% of the patients were free from rethrombosis.
Subject(s)
Fibrinolytic Agents/therapeutic use , Heart Valve Prosthesis/adverse effects , Streptokinase/therapeutic use , Thrombolytic Therapy/methods , Thrombosis/drug therapy , Adolescent , Adult , Child , Cineradiography , Echocardiography, Doppler , Echocardiography, Transesophageal , Female , Follow-Up Studies , Humans , Male , Middle Aged , Prospective Studies , Thrombosis/diagnosis , Thrombosis/etiology , Treatment OutcomeABSTRACT
OBJECTIVE: To assess the short- and long-term results of the use of streptokinase (SK) for the treatment of thromboses in cardiac valvular prostheses. METHODS: Seventeen patients with cardiac prosthetic thrombosis diagnosed by clinical, echocardiographic, and radioscopic findings underwent fibrinolytic treatment with a streptokinase bolus of 250,000 U followed by 100.000 U/hour. Short- and long-term results were assessed by radioscopy and echocardiography. RESULTS: Of the 17 patients, 12 had mechanical double-disk prostheses (4 aortic, 6 mitral, 2 tricuspid), 4 had single-disk prostheses (2 aortic, 1 mitral, and 1 tricuspid), and 1 had a tricuspid bioprosthesis. The success rate was 64.8 percent, the partial success rate was 17.6 percent, and the nonsuccess rate was 17.6 percent. All patients with a double-disk prosthesis responded, completely or partially, to the treatment. None of the patients with a single-disk prosthesis had complete resolution of the thrombosis. The time of streptokinase infusion ranged from 6 to 80 hours (mean of 56 h). The mortality rate due to the use of streptokinase was 5.8 percent and was secondary to cerebral bleeding. During streptokinase infusion, 3 (17.6 percent) embolic episodes occurred as follows: 1 cerebral, 1 peripheral, and 1 coronary. The rethrombosis index was 33 percent in a mean follow-up of 42 months. CONCLUSION: The use of fibrinolytic agents was effective and relatively safe in patients with primary thrombosis of a double-disk prosthesis. A fatal hemorrhagic complication occurred in 1 (5.8 percent) patient, and embolic complications occurred in 3 (17.6 percent) patients. In a mean 42-month follow-up, 67 percent of the patients were free from rethrombosis