Аннотация
Список литературы
Хирургическое протезирование клапанов по-прежнему остается одним из основных методов лечения пациентов с тяжелыми клапанными пороками сердца. Тромбоз механических протезов клапанов сердца является самой частой причиной их дисфункции и относится к жизнеугрожающим состояниям. Риск этого осложнения зависит от типа протеза, адекватности проводимой антикоагулянтной терапии, позиции клапана и наличия протромботических состояний. Неадекватная антикоагулянтная терапия с субтерапевтическим уровнем международного нормализованного отношения является наиболее важным фактором риска образования тромбов на протезированных клапанах. В статье описаны клинические признаки обструктивного и необструктивного тромбоза клапанов, а также современные методы его диагностики. Показано, что применение современных визуализирующих методов исследования имеет важное клиническое значение для определения этиологии дисфункции протезированного клапана, проведения дифференциальной диагностики между тромбом и паннусоми, а также для выбора дальнейшей лечебной тактики. Основными методами диагностики тромбоза протезированного клапана являются трансторакальная и чреспищеводная эхокардиография. При их недостаточной информативности применяют мультидетекторную компьютерную томографию. В настоящее время оптимизация антикоагулянтной терапии, тромболизис и хирургическое вмешательство являются основными методами лечения пациентов с данной патологией. Отмечено, что рандомизированных проспективных исследований, сравнивающих эффективность и безопасность хирургического лечения и тромболитической терапии при тромбозе механических протезов клапанов, недостаточно. Однако имеются доказательства, что применение низкодозовой медленной или сверхмедленной внутривенной инфузии тканевого активатора плазминогена под контролем чреспищеводной эхокардиографии приводит к высокой эффективности тромболизиса с низким уровнем осложнений и летальности.
Ключевые слова:
тромбоз, механические протезы клапанов сердца, трансторакальная эхокардиография, чреспищеводная эхокардиография, мультидетекторная компьютерная томография, тромболизис, хирургическое лечение.
Mechanical prosthetic heart valve thrombosis in clinical practice
Surgery plays a central role in the management of acquired valvular heart disease. Prosthetic valve thrombosis is a rare but serious life-threatening complication of valve replacement, most often encountered with mechanical prostheses. The risk of valve thrombosis depends on the type of prosthesis, the adequacy of anticoagulant therapy, the position of the valve and the presence of prothrombotic conditions. Inadequate level of anticoagulation is the most important factor involved in the pathogenesis of prosthetic valve thrombosis. The severity of symptoms highly depends on the degree of valve obstruction caused by the prosthetic valve thrombosis. Multimodality imaging is crucial in the diagnosis and management of prosthetic heart valve thrombosis and also for differential diagnosis between thrombus and pannus. Optimization of anticoagulant therapy, thrombolysis and surgical intervention are the main methods of treatment of patients with valve thrombosis. Thrombolytic therapy has become an alternative to surgery in the treatment of obstructive prosthetic valve thrombosis in recent years. The use of low-dose slow or ultraslow intravenous infusion of tissue plasminogen activator under the control of transesophageal echocardiography leads to high efficiency of thrombolysis with a low level of complications and mortality. The efficacy and safety of thrombolysis compared to surgery should be confirmed with the results of large observational and randomized trials.
Keywords
thrombosis, mechanical prosthetic heart valve, transthoracic echocardiography, transesophageal echocardiography, multidetector computer tomography, thrombolysis, surgery.
-
1. Schaff, H. V. Progress in Management of Mechanical Valve Thrombosis // J Am Coll Cardiol. – 2022. – Vol. 79, № 10. – P. 990–992. – doi: 10.1016/j.jacc.2022.01.008. 2. Symersky, P. Comparison of multidetector-row computed tomography to echocardiography and fluoroscopy for evaluation of patients with mechanical prosthetic valve obstruction / P. Symersky, R. Budde, B. De Mol, P. Mathias // Am J Cardiol. – 2009. – Vol. 104, № 8. – P. 1128–1134. – doi: 10.1016/j. amjcard.2009.05.061. 3. Otto, C. M. 2020 ACC/AHA guideline for the management of patients with valvular heart disease / C. M. Otto, R. A. Nishimura, R. O. Bonow [et al.] // J Am Coll Cardiol. – 2021. – Vol. 77, № 4. – P. 25–197. – doi: 10.1016/j.jacc.2020.11.018. 4. Praz, F. 2025 ESC/EACTS guidelines for the management of valvular heart disease / F. Praz, M. Borger, J. Lanz [et al.] // Eur Heart J. – 2025. – Vol. 46. – P. 4635–4736. – doi: 10.1093/ eurheartj/ehaf194. 5. Biteker, M. Treatment of Prosthetic Valve Thrombosis: Current Evidence and Future / M. Biteker, I. Altun, O. Basaran, V. Dogan // J Clin Med Res. – 2015. – Vol. 7, № 12. – P. 932–936. – doi: 10.14740/jocmr2392w. 6. Zoghbi, W. A. Recommendations for evaluation of prosthetic valves with echocardiography and Doppler ultrasound: a report from the American Society of Echocardiography’s Guidelines and Standards Committee / W. A. Zoghbi, J. B. Chambers, J. G. Dumesnil [et al.] // J Am Soc Echocardiogr. – 2009. – Vol. 22, № 9. – P. 975–1014. – doi: 10.1016/j.echo.2009. 07.013. 7. Yoganathan, A. P. Fluid mechanics of heart valves / A. P. Yoganathan, Z. He, S. C. Jones // Annu Rev Biomed Eng. – 2004. – Vol. 6. – P. 331–362. – doi: 10.1146/annurev.bioeng. 6.040803.140111. 8. Jaffer, I. H. Medical device-induced thrombosis: what causes it and how can we prevent it? / I. H. Jaffer, J. C. Fredenburgh, J. Hirsh, J. I. Weitz // J Thromb Haemost. – 2015. – Vol. 13, № 1. – P. 72–81. – doi: 10.1111/jth.12961. 9. Lancellotti, P. Recommendations for the imaging assessment of prosthetic heart valves: A report from the European Association of Cardiovascular Imaging endorsed by the Chinese Society of Echocardiography, the Inter-American Society of Echocardiography, and the Brazilian Department of Cardiovascular Imaging / P. Lancellotti, P. Pibarot, J. Chambers [et al.] // Eur Heart J Cardiovasc Imaging. – 2016. – Vol. 17, № 6. – P. 589–590. – doi: 10.1093/ehjci/jew025. 10. Gündüz, S. Diagnosis, treatment & management of prosthetic valve thrombosis: The key considerations / S. Gündüz, M. Kalçık, M. O. Gürsoy, A. Güner, M. Özkan // Expert Rev Med Devices. – 2020. – Vol. 17, № 3. – P. 209–221. – doi: 10.1080/17434440.2020.1733972. 11. Dürrleman, N. Prosthetic valve thrombosis: twenty-year experience at the Montreal Heart Institute / N. Dürrleman, M. Pellerin, D. Bouchard [et al.] // J Thorac Cardiovasc Surg. – 2004. – Vol. 127, № 5. – P. 1388–1392. – doi: 10.1016/j. jtcvs.2003.12.013. 12. Muratori, M. Feasibility and diagnostic accuracy of quantitative assessment of mechanical prostheses leaflet motion by transthoracic and transesophageal echocardiography in suspected prosthetic valve dysfunction / M. Muratori, P. Montorsi, G. Teruzzi [et al.] // Am J Cardiol. – 2006. – Vol. 97, № 1. – P. 94–100. – doi: 10.1016/j.amjcard.2005.07.112. 25. Tong, A. T. Transesophageal echocardiography improves risk assessment of thrombolysis of prosthetic valve thrombosis: results of the international PRO-TEE registry/ A. T. Tong, R. Roudaut, M. Ozkan [et al.] // J Am Coll Cardiol. – 2004. – Vol. 43, № 1. – P. 77–84. – doi: 10.1016/j.jacc.2003.08.028. 26. Özkan, M. Thrombolytic therapy for the treatment 13. Philippe Généreux, Ph. Valve Academic Research Consortium 3: Updated Endpoint Definitions for Aortic Valve Clinical Research / Ph. Généreux, N. Piazza, M. Alu [et al.] // Am Coll Cardiol. – 2021. – Vol. 77, № 21. – P. 2717–2746. – doi: 10.1016/j.jacc.2021.02.038. 14. Muratori, M. The Role of Multimodality Imaging in LeftSided Prosthetic Valve Dysfunction / M. Muratori, L. Fusini, M. Mancini [et al.] // J Cardiovasc Dev Dis. – 2022. – Vol. 9, № 1. – P. 12. – doi: 10.3390/jcdd9010012. 15. Pibarot, P. Prosthetic heart valves: Selection of the optimal prosthesis and long-term management / P. Pibarot, J. G. Dumesnil // Circulation. – 2009. – Vol. 119, № 7. – P. 1034–1048. – doi: 10.1161/CIRCULATIONAHA.108.778886. 16. Ben Zekry, S. Flow acceleration time and ratio of acceleration time to ejection time for prosthetic aortic valve function / S. Ben Zekry, R. M. Saad, M. Ozkan [et al.] // J Am Coll Cardiol Img. – 2011. – Vol. 4, № 11. – P. 1161–1170. – doi: 10.1016/ j.jcmg.2011.08.012. 17. Ozkaramanli Gur, D. Evaluation of mechanical prosthetic valves: the role of 3 dimensional echocardiography in calculating effective orifice area in obese vs non-obese individuals / D. Ozkaramanli Gur, D. Baykiz, O. Gur [et al.] // Int J Cardiovasc Imaging. – 2021. – Vol. 37, № 1. – P. 215–227. – doi: 10.1007/ s10554-020-01978-3. 18. Kim, J. Y. Diagnostic Value of Advanced Imaging Modalities for the Detection and Differentiation of Prosthetic Valve Obstruction: A Systematic Review and Meta-Analysis / J. Y. Kim, Y. J. Suh, K. Han [et al.] // Han JACC Cardiovasc. Imaging. – 2019. – Vol. 12, № 11. – P. 2182–2192. – doi: 10.1016/j.jcmg.2018.11.033. 19. Guner, A. What is the importance of real-time three dimensional transesophageal echocardiography and time in therapeutic range in patients with prosthetic valve throm- bosis? / A. Guner, M. Kalcik, M. O. Gursoy [et al.] // J Thromb Thrombolysis. – 2018. – Vol. 46, № 1. – P. 79–80. – doi: 10.1007/s11239-018-1655-9 . 20. Suchá, D., Symersky P., Tanis W., Mali W. P., Leiner T., van Herwerden L. A., Budde R. P. Multimodality Imaging Assessment of Prosthetic Heart Valves / D. Suchá, P. Symersky, W. Tanis [et al.] // Circ Cardiovasc Imaging. – 2015. – Vol. 8, № 9. – Р. e003703. – doi: 10.1161/CIRCIMAGING.115.003703. 21. Gündüz, S. Sixty-foursection cardiac computed tomography in mechanical prosthetic heart valve dysfunction: thrombus or pannus / S. Gündüz, M. Özkan, M. Kalçik [et al.] // Circ Cardiovasc Imaging. – 2015. – Vol. 8, № 12. – Р. e003246. – doi: 10.1161/CIRCIMAGING.115.003246. 22. Özkan, M. Intravenous thrombolytic treatment of mechanical prosthetic valve thrombosis: A study using serial transesophageal echocardiography / M. Özkan, C. Kaymaz, C. Kirma [et al.] // J Am Coll Cardiol. – 2000. – Vol. 35, № 7. – P. 1881–1889. – doi: 10.1016/s0735-1097(00)00654-9. 23. Özkan, M. Comparison of different TEE-guided thrombolytic regimens for prosthetic valve thrombosis: the TROIA trial / M. Özkan, S. Gunduz, M. Biteker [et al.] // JACC Cardiovasc Imaging. – 2013. – Vol. 6, № 2. – P. 206–216. – doi: 10.1016/ j.jcmg.2012.10.016. 24. Chopard, R. Surgery Versus Thrombolytic Therapy for the Management of Left-Sided Prosthetic Valve Thrombosis Without Hemodynamic Compromise: A Systematic Review and Meta-Analysis / R. Chopard. Ch. Vidoni, M. Ismail [et al.] // J Am Heart Assoc. – 2024. – Vol. 13, № 19. – Р. e035143. – doi: 10.1161/JAHA.124.035143.
of prosthetic heart valve thrombosis in pregnancy with lowdose, slow infusion of tissue-type plasminogen activator / M. Özkan, B. Çakal, S. Karakoyun [et al.] // Circulation. – 2013. – Vol. 128, № 5. – P. 532–540. – doi: 10.1161/CIRCULATIONAHA.113. 001145. 27. Özkan, M. Ultraslow thrombolytic therapy: a novel strategy in the management of PROsthetic Mechanical valve Thrombosis and the prEdictors of outcomE: the ultra-slow PROMETEE trial / M. Özkan, S. Gündüz, O. M. Gürsoy [et al.] // Am Heart J. – 2015. – Vol. 170, № 2. – P. 409–418. – doi: 10.1016/j.ahj.2015.04.025. 28. Nishanth, K. R. Fibrinolysis in left-sided mechanical prosthetic valve thrombosis with high INR / K. R. Nishanth, M. Shankar, K. H. Srinivasa [et al.] // Eur Heart J Acute Cardiovasc Care. – 2020. – Vol. 9, № 3. – P. 58–62. – doi: 10.1177/ 2048872619846329. 29. Özkan, M. Gündüz S, Güner A, et al. Thrombolysis or surgery in patients with obstructive mechanical valve thrombosis: the multicenter HATTUSHA study / M. Özkan, S. Gündüz, A. Güner [et al.] // J Am Coll Cardiol. – 2022. – Vol. 79, № 10. – P. 977–989. – doi: 10.1016/j.jacc.2021.12.027. 30. Gündüz, S. Prolonged Infusions of Low-Dose Thrombolytics in Elderly Patients With Prosthetic Heart Valve Thrombosis / S. Gündüz, M. Özkan, M. Yesin [et al.] // Clin Appl Thromb Hemost. – 2017. – Vol. 23, № 3. – P. 241–247. – doi: 10.1177/1076029615609698. 31. Taherkhani, M. Thrombolytic therapy for right-sided mechanical pulmonic and tricuspid valves: the largest survival analysis to date / M. Taherkhani, S. R. Hashemi, M. Hekmat [et al.] // Tex Heart Inst J. – 2015. – Vol. 42, № 6. – P. 543–547. – doi: 10.14503/THIJ-14–4 659. 32. Vihinen, T. Knock knock knocking on: how to open stuck mitral valve prosthesis / T. Vihinen, J. Lund, K. E. [et al.] // Airaksinen Eur Heart J. – 2011. – Vol. 32, № 15. – P. 1947. – doi: 10.1093/eurheartj/ehr094. 33. Hariram, V. Percutaneous management of prosthetic valve thrombosis // Indian Heart J. – 2014. – Vol. 66, № 4. – P. 427–429. – doi: 10.1016/j.ihj.2014.05.008. 34. Chen, Y. Percutaneous transcatheter release of stuck mechanical mitral valve leaflet / Y. Chen, R. Waksman, L. Satler [et al.] // Eur Heart J. – 2020. – Vol. 41, № 41. – P. 4072. – doi: 10.1093/eurheartj/ehaa228. 35. Deviri, E. Obstruction of mechanical heart valve prostheses: clinical aspects and surgical management / E. Deviri, P. Sareli, T. Wisenbaugh, S. L. Cronje // J Am Coll Cardiol. – 1999. – Vol. 17, № 3. – P. 646–650. – doi: 10.1016/s07351097(10)80178-0. 36. Joseph, S. The thrombosed prosthetic valve: current recommendations based on evidence from the literature // J Am Coll Cardiol. – 2003. – Vol. 41, № 4. – P. 659–660. – doi: 10.1016/s0735-1097(02)02871-1. 37. Karthikeyan, G. Urgent surgery compared with fibrinolytic therapy for the treatment of left-sided prosthetic heart valve thrombosis: a systematic review and meta-analysis of observational studies / G. Karthikeyan, N. Senguttuvan, J. Joseph [et al.] // Eur Heart J. – 2013. – Vol. 34, № 21. – P. 1557–1566. – doi: 10.1093/eurheartj/ehs486. 38. Castilho, F. M. Thrombolytic therapy or surgery for valve prosthesis thrombosis: systematic review and meta-analysis / F. M. Castilho, M. R. De Sousa, A. L. Mendonça [et al.] // J Thromb Haemost. – 2014. – Vol. 12, № 8. – P. 1218–1228. – doi: 10.1111/jth.12577.