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[A case of thrombosed St. Jude Medical valve 16 years after initial mitral valve replacement]
A Morishita1, T Shimakura, M Nonoyama
1Department of Cardiovascular Surgery, Fukuyama Cardiovascular Hospital, Hiroshima, Japan.
Insights
Late-onset St. Jude Medical valve thrombosis occurred 16 years post-replacement despite adequate anticoagulation. Surgical valve replacement was successful, suggesting implantation orientation may influence thrombosis risk.
Area of Science:
- Cardiology
- Cardiac Surgery
- Biomaterials Science
Background:
- Mitral valve replacement aims to restore cardiac function.
- St. Jude Medical (SJM) valves are commonly used prosthetic devices.
- Valve thrombosis is a known complication, typically occurring within 5 years post-implantation.
Observation:
- A 61-year-old female presented with symptoms suggestive of prosthetic valve dysfunction 16 years after SJM mitral valve replacement.
- Despite satisfactory anticoagulation, echocardiography revealed leaflet immobility and a soft tissue mass, indicative of thrombosis.
- Intravenous thrombolysis with urokinase was ineffective in restoring leaflet mobility.
Findings:
- Surgical exploration identified significant thrombus obstructing the SJM valve leaflet, necessitating valve explantation.
- The prosthetic valve was replaced with a CarboMedics valve.
- Histopathological examination confirmed the presence of both old and fresh thrombi.
Implications:
- Valve thrombosis can occur late, even with reliable prosthetic valves and adequate anticoagulation.
- The anatomical orientation during SJM valve implantation may be a critical factor in preventing late thrombosis.
- Further research into optimal prosthetic valve implantation techniques is warranted to minimize thrombotic complications.
Abstract:
We report successful surgery for a thrombosed St. Jude Medical (SJM) valve 16 years after the initial mitral valve replacement even under conditions of satisfactory anticoagulation therapy. A 61-year-old-female had intermittent claudication and was admitted to our hospital for examination. The prosthetic valve sounds were normal to auscultation and the left ankle-pressure index was decreased to 0.6. Transthoracic echocardiography revealed no mitral regurgitation and a mean mitral valve gradient of 6-7 mmHg. Furthermore, transesophageal echocardiography revealed that one of the leaflets of the prosthetic valve was entirely immobilized at the closing position and a mobile soft tissue mass, 5 mm in diameter, was detected at the atrial side of the obstructed leaflet. Although 96,0000 IU of urokinase was administered intravenously for a week, we could not confirm any change in leaflet mobility. At the time of surgery, the posterior leaflet of the SJM valve, which was implanted at an anatomical orientation, was obstructed at the closing position with old and fresh thrombi. We decided upon replacement with a CarboMedics 29 M prosthetic valve. Postoperative medication consisted of warfarin plus low-dose aspirin. Generally, valve thrombosis occurs within 5 years after valve replacement. However, valve thrombosis is possible even in a reliable SJM valve and as long as 16 years after replacement. Therefore, the implantation of an SJM valve at an anti-anatomical orientation might lower the incidence of valve thrombosis in addition to life-long anticoagulation therapy.