OBSTRUCTED MECHANICAL VALVE

1. OBSTRUCTED MECHANICAL VALVE NOW WHAT? Blasé Carabello, MD

2. MAKE SURE IT’S OBSTRUCTED

3. 68 Y/O MAN • 3 Yrs S/P 25mm St. Judes AVR • PROGRESSIVE DOE OVER PAST 3mo • PE: SHARP PV CLICKS

4. ECHO • PV MOVEMENT NL • JET 3.1 m/sec • AVA 0.9 cm2 • EF 0.2

6. 67 Y/O MAN • 3 YEARS S/P 31 mm St. Judes MVR • 1 BLOCK DOE WORSENED FROM 2 mo AGO • 2 cm THROMBUS IMPAIRING LEAFLET MOTION MEAN GRADIENT 10 mm Hg

7. IS IT PANNUS OR THROMBOSIS • URGENT TEE

8. NOTHING APPROACHING RANDOMIZED DATA

9. THOMBOSIS • 0.05 to 1% PER PT-YR • MODERN MORTALITY ~ 10% MOST ARE NYHA III OR IV

10. ROUDAUT et al • 210 PTS • 127 Rxd WITH THROMBOLYTICS • 136 Rxd WITH SURGERY • MORTALITY IDENTICLE (10%)

11. DIFFERENCES • HEMODYNAMIC SUCCESS 89% Sx VS 70% TL • STROKE 0.7% Sx VS 15% TL • NYHA CLASS MOST SIGNIFICANT PREDICTOR

12. TONG et al • RISK OF COMPLICATIONS--- 2.41/cm2 THROMBUS SIZE • LOW RISK < 0.8 cm2

13. THERAPEUTIC PARADOX • THE PATIENTS MOST OFTEN JUDGED “TOO SICK” FOR SURGERY DO THE POOREST WITH THROMBOLYTICS

14. TRICUSPID THROMBOSIS • MAY OCCUR IN AS MANY AS 20% OF TV MECHANICAL PROSTHESIS • DEVASTATING COMPLICATIONS LESS COMMON THAN WITH L SIDED DISEASE

15. GUIDELINES NO CLASS I THERAPEUTIC INDICATIONS

16. 2a • SURGERY FOR CLASS III AND IV PATIENTS • LYTICS FOR A SMALL CLOT BURDEN • SURGERY FOR A LARGE CLOT BURDEN

17. 2b • HEPARIN FOR CLASS I AND II WITH A SMALL CLOT BURDEN • LYTICS FOR CLASS I AND II WITH A SMALL CLOT BURDEN • LYTICS FOR CLASS III AND IV IF HIGH RISK FOR SURGERY AND SMALL CLOT BURDEN

18. LYTICS FOR CLASS II-IV IF SURGERY IS UNAVAILABLE • HEPARIN FOR CLASS II PATIENTS AND SMALL CLOT BURDEN