JACC V) 4, No.4October I~84:779-83

Nonsurgical Correction of a "Frozen" Disc Valve Prosthesis Using aCatheter Technique and Intracardiac Streptokinase Infusion

GEOFFREY O. HARTZLER, MD, FACC, ANTONI M. DIEHL, MD, FACe,

WILUAM A. REED, MD, FACC

Kansa City, Missouri

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HARTZLER ET AL.NONSURGICAL CORRECTION OF A " FROZEN" DISC VALVE

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Figure 2. Left, SF balloon flotationcathete- is inflated within the pulmo-nary arterydistal to the immobile disc.The arrows indicate the inflated bal-loon. Right, Pressure is being appliedagainst the immobile disc by a firmtugging of the balloon catheter. Notethe slight change in the position of thedisc.

tain the partial thromboplastin time between I V2to 2V2timescontrol values for a 24 hour period. Prosthetic valve soundsremained crisp . Medications at hospital discharge includedaspiri n. 300 mg daily. and dipyridamole, 25 mg three timesdaily. o\t4 months' follow-up. the prosthetic valve functionremained normal. disc sounds were crisp and the patientwas clmically uncompromised.

DiscussionThere is no ideal prosthetic valve for implantation in

children. For a variety of unique reasons, both bioprostheticand mechanical valves have increased failure rates relativeto their use in adults (1). An increased incidence of throm-boembolic complications in children with mechanical valvesincludes valve thrombosis as illustrated by our patient.

Since the morbidity associated with long-term antico-agulation therapy in childhood is significantly increased , theuse oj warfarin therapy is controversial. However. currentrecommendations for children with a mechanical valve pros-thesis include I) long-term warfarin anticoagulation . 2) an-tiplaielet therapy with aspir in alone or in comb ination withdipyridamole, or 3) no drug therapy (2).

Prosthetic valve thrombosis. Acquired Bjork-Shileyprosthetic valve dysfunction caused by thrombus formationis an uncommon but recognized complication (3- 6). Gen-erally . surgical thrombectomy or valve replacement has beenrecommended , particularly for prostheses in the aortic andmitral position s. However. several report s (7- 9) have de-scribed effective thrombolytic therapy for obstru ctedprosthese s in the aortic , mitral and tricuspid position .

The occurrence of prosthetic valve thromb osis in thepediatric age group repres ents a disappointing and compl exmanagement problem. We are unaware of any previou sreports of effective thrombolytic therapy for Bjork-Shiley

valve thrombosis in childhood. The risks of reoperation aresignificant and the procedure may be further complicatedby the presence of an anteriorly positioned, retrosternal con-duit , as in our patient. Consequently, this demonstrationthat an immobile disc valve prosthesis can be restored tonormal function without reoperation and without compli-cating sequelae is of major importance.

Catheter technique. To our knowledge , this is the firstreported incidence of nonsurgical transvenous catheter cor-rection of an immobile , apparently thrombosed disc valveprosthesis. The relative efficacy of mechanical tugging againstthe disc as compared with that of a streptokinase infusionalone is uncertain. However , it is our impression that force-ful c , grasping" of the disc was the most effective maneuverin restoring motion. It is possible that a prolonged intra-cardiac streptokinase infusion or even intravenous infusionmay have eventually resulted in complete thrombolysis withrelease of the disc . However, it is also possible that strep-tokinase alone could not have effectively lysed a nonacutethrombus and that this mechanical disruption was necessaryto enhance dissolution of thrombus and restore full discmotion.

There was no clinic al or chest X-ra y evidence of distalpulmonary embolization. However, pulmonary angiogra-phy. lung scans and arterial blood gas assessments were notobtained after the procedure. Although embolization mayhave occurred, it is likely that the lytic effects of strepto-kinase and the infusion of continuous intravenous heparinwould have prevented signifcant or detectable sequelae .

Conclusions. On the basis of this single case experience ,we believe that a similar approach should be considered forfuture cases of right-sided prosthetic valve dysfunction. In-trinsic mechanical faults with in the valve structure prob ablywould not be amenable to correction by this techn ique .Howev er. if clinical and circumstantial evidence favors theoccurrence of recent thrombosis as the cause of acquired

Figure 3. Identical cinefluoroscopic sequence as in Figure 1, obtained after transvenous catheter correction of the immobile disc. Thearrow indicates the edge of the now freely and fully mobile disc during a complete cardiac cycle.

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JACe Vo 4, No 4October 1)84'779-83

HARTZLER ET ALNONSURGICAL CORRECTION OF A "FROZEN" DISCVALVE

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valve dysfunction, an attempt at correction using combinedmechanical anddrug-induced thrombolysis maybejustified.

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oprm .nt of artificial heart valve substitutes for use in infantsand smallchildren. J Thorac Cardiovasc Surg 1976;72:539-46.

2. Weue-tein OS, Mavroudis C. Ebert PA Preliminary experience withaspirin anticoagulation in childrenwith prosthetic cardiacvalves. AnnThoiac Surg 1982;33:549-53.

3, Bjor«VO,HenzeA. Ten years' expenencewiththe Bjork-Shiley tiltingdisc valve. J Thorac Cardiovasc Surg 1979;78:331-42.

4. KaTJ' RB, Zyrus RJ, Blackstone PH, Kirklin JW, Kouchoukos NT,Pacrico AB. The Bjork-Shiley valve: intermediate-term follow-up, JTho-uc Cardiovasc Surg 1981;81:602-14.

5. Fernandez 1, Samuel A, Yang SS, et al, Late thrombosis of the aorticBjork-Shiley prosthesis. Itsclinical recognition and management. Chest1976;70:12-16.

6, Moreno-Cabral RJ, McNamara Jl. Mamiya RT, Brainard SC, ChungOKT. Acute thrombotic obstruction with Bjork-Shiley valves. Diag-nostic and surgical considerations. J Thorac Cardiovasc Surg1978:75:321-30.

7. Luluaga IT, Carrera D. d'Oliviera J. Successfulthrombolytic therapyafter acute tricuspid vaJve obstruction (letter). Lancet 1971;1:1067-8.

8. Hellestrand KJ, Morgan JJ, Chang VP. Thrombolytic therapy for athrombosed Bjork-Shiley tncuspid valve prosthesis. Clin Cardiel1982;5:347-50.

9. Witchitz S, Veyrat C, Moisson P, Scheinman N, Rozenstajn L. Fi-brinolytic treatment of thrombus on prosthetic heart valves. Br HeartJ 1980;44:545-54.