Nonsurgical correction of a “Frozen” disc valve prosthesis ...This patient, a SV2 year-old girl,...
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JACC V) 4, No.4 October I Nonsurgical Correction of a "Frozen" Disc Valve Prosthesis Using a Catheter Technique and Intracardiac Streptokinase Infusion GEOFFREY O. HARTZLER, MD, FACC, ANTONI M. DIEHL, MD, FACe, WILUAM A. REED, MD, FACC Kansa City, Missouri 779 <\n immobile disc of a Bjork-Shiley valve prosthesis po- sitioned within a right ventricle to main pulmonary ar- tery conduit was restored to normal function through Acquired prosthetic valve malfunction almost invariably re- quires operative revision. We report the nonsurgical cor- rection of a "frozen" Bjork-Shiley disc prosthesis using a transvenous catheter technique and intracardiac infusion with streptokinase. Case Report This patient, a SV2 year-old girl, underwent a right Bla- lock-Taussig anastomosis for palliation of tetralogy of Fallot with pulmonary valve atresia at 13 days of age. At 3 years of age. repeat catheterization demonstrated systemic right ventricular pressures and a total right to left shunt through the large subaortic ventricular septal defect. The pulmonary artery pressure and pulmonary vascular resistance measured through the Blalock-Taussig shunt were low. At 4 years of age, in May 1982, a second operation was performed. The pulmonary shunt was taken down and the ventricular septal defect was closed with a patch. Because of anomalous left coronary distribution, crossing the right ventricular outflow tract In combination with virtual pulmonary atresia. a stan- dard right ventriculotomy with infundibular resection or patch reconstruction was not performed. Instead, an 18 mm tu- bular conduit with a 16 mm Bjork-Shiley disc prosthesis was placed from the right ventricle to the main pulmonary artery. Postoperative course, The late postoperative course was uneventful with excellent clinical results that included ab- From the Mid-America Heart Institute. St. Luke's Hospital, Kansas City, Missouri. Manuscript received January 30. 1984; revised manuscript received May 2, 1984, accepted May 17, 1984. Address for reprints: Geoffrey O. Hartzler, MD, Mid-Amenca Heart Institute, St. Luke's Hospital, 44th and Womall Street, Kansas City, Mis- soun 64111. © 1984 I)V the Amencan College of Cardiology mechanical tugging of a balloon catheter combined with selective right ventricular streptokinase infusion. sence of cyanosis, improved exercise tolerance and crisp prosthetic valve sounds. One year later in May 1983, the prosthetic valve sounds were noted to be normal at routine cardiac reevaluation. However, 1 month later when the pa- tient was hospitalized for elective cardiac catheterization, the prosthetic valve sounds were absent. Echocardiography confirmed the clinical impression of an immobile disc with- out demonstration of thrombus. Fluoroscopy at repeat catheterization demonstrated the immobile prosthetic valve disc that was "frozen" in an approximate two-thirds open position (Fig, I), presumably resulting from localized thrombus formation. However, right ventricular angiography did not demonstrate a filling defect within or immediately adjacent to the prosthesis. The ven- tricular septum was intact with no right to left or left to right shunts. Right ventricular systolic pressure was at the sys- temic level of 80 mm Hg with a 45 mm transprosthetic valve gradient. Corrective catheterization procedure, With parental informed consent, 4 days later at second procedure using standard percutaneous techniques, a right ventricular infu- sion of streptokinase was commenced at 5,000 units/min. There was no change in disc mobility within 15 minutes. Consequently, a SF balloon flotation catheter was passed through the conduit, across the open disc and inflated within the pulmonary artery (Fig. 2, left). With repeated tugging against the open disc, partial motion was restored within a few minutes. Streptokinase was continued for a total dose of 130,000 units/min while repeated tugging against the disc was performed (Fig. 2, right). Within 20 minutes, full disc motion was restored (Fig. 3) and the right ventricular pres- sure decreased to 35 mm Hg systolic with a main pulmonary artery pressure of 20 mm Hg. After the corrective catheterization procedure, the patient received a continuous intravenous heparin infusion to main- 0735-1097/84/$3 00
Transcript of Nonsurgical correction of a “Frozen” disc valve prosthesis ...This patient, a SV2 year-old girl,...
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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
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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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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.
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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.
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