Sources of Thromboembolism in Patients with Correctly Functioning Mechanical Valves: A Single-Center Transesophageal Echocardiographic Study


  • Marek Maciejewski
  • Katarzyna Piestrzeniewicz
  • Ryszard Jaszewski
  • Agata Bielecka-Dabrowa
  • Jan H. Goch



Background: In patients with mechanical prostheses (MP), thromboembolism is one of the most serious complications. The study aim was to assess the incidence of sources of thromboembolism in patients with correctly functioning MP with and without a history of thromboembolism.

Methods: Two hundred ninety-seven patients with correctly functioning MP were enrolled in this single-center, transesophageal echocardiographic (TEE), retrospective, observational study. Two groups were analyzed: Group A, 183 patients with a history of thromboembolism, and Group B, 114 patients with no history of thromboembolism.

Results: Definite sources of thromboembolism were revealed in 59% of patients in Group A, and sources of potential thromboembolism were revealed in 13% of patients in Group B (P < .001). Multiple sources of thromboembolism were present in 9% of patients in Group A and 1% of patients in Group B. Localization of sources of thromboembolism included MP ring (59% and 53% of patients in Groups A and B, respectively); left atrium/left atrium appendage (24%/21% and 13%/40% of patients in Groups A and B, respectively); and aorta (12% and 13% of patients in Groups A and B, respectively). Patients with multiple sources of thromboembolism were older (P < .001) and in a higher New York Heart Association (NYHA) class (P = .004). Patients with sources of thromboembolism in the aorta were older than the rest of the group (P < .01).

Conclusions: In patients with correctly functioning MP, sources of thromboembolism are observed 4 times more often in case of the positive history of thromboembolism. The most common source of thromboembolism is thrombosis of MP ring. Age and heart failure predispose multiple sources of thromboembolism. One might consider control TEE after mechanical valve implantation, but only in selected group of patients without embolic events but with a higher risk of thromboembolism.


Aagaard J, Tingleff J. 2005. Fifteen years' clinical experience with the CarboMedics prosthetic heart valve. J Heart Valve Dis 14:82-8.nBarbetseas J, Pitsavos C, Aggeli C, et al. 1997. Comparison of frequency of left atrial thrombus in patients with mechanical prosthetic cardiac valves and stroke versus transient ischemic attacks. Am J Cardiol 80:526-8.nBlack IW, Hopkins AP, Lee LC, Walsh WF. 1991. Left atrial spontaneous echo contrast: a clinical and echocardiographic analysis. J Am Coll Cardiol 18:398-404.nBonow RO, Carabello B, de Leon AC, et al. 1998. ACC/AHA guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association. Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease). J Am Coll Cardiol 32:1486-588.nButchart EG, Ionescu A, Payne N, Giddings J, Grunkemeier GL, Fraser AG. 2003. A new scoring system to determine thromboembolic risk after heart valve replacement. Circulation 108:II68-74.nButchart EG, Li HH, Payne N, Buchan K, Grunkemeier GL. 2001. Twenty years' experience with the Medtronic Hall valve. J Thorac Cardiovasc Surg 121:1090-100.nChang BC, Lim SH, Kim DK, et al. 2001. Long-term results with St. Jude Medical and CarboMedics prosthetic heart valves. J Heart Valve Dis 10:185-94.nDürrleman N, Pellerin M, Bouchard D, et al. 2004. Prosthetic valve thrombosis: twenty-year experience at the Montreal Heart Institute. J Thorac Cardiovasc Surg 127:1388-92.nEdmunds LH Jr. 1982. Thromboembolic complications of current cardiac valvular prostheses. Ann Thorac Surg 34:96-106.nFinkelhorn RS, Lamont WE, Ramanavarapu SK, Bahler RC. 1995. Spontaneous echocardiographic contrast in the thoracic aorta: factors associated with its occurrence and its association with embolic events. Am Heart J 130:1254-8.nFinkelhorn RS, Youssefi ME, Lamont WE, Bahler RC. 1999. Embolic risk based on aortic atherosclerotic morphologic features and aortic spontaneous echocardiographic contrast. Am Heart J 137:1088-93.nGrunkemeier GL, Starr A. 1988. Twenty-five year experience with Starr-Edwards heart valves: follow-up methods and results. Can J Cardiol 4:381-5.nGueret P, Vignon P, Fournier P, et al. 1995. Transesophageal echocardiography for the diagnosis and management of nonobstructive thrombosis of mechanical mitral valve prosthesis. Circulation 91:103-10.nKaralis DG, Chandrasekaran K, Victor MF, Ross JJ Jr, Mintz GS. 1991. Recognition and embolic potential of intraaortic atherosclerotic debris. J Am Coll Cardiol 17:73-8.nKaralis DG, Quinn V, Victor MF, et al. 1996. Risk of catheter-related emboli in patients with atherosclerotic debris in the thoracic aorta. Am Heart J 131:1149-55.nLaplace G, Lafitte S, Labèque JN, et al. 2004. Clinical significance of early thrombosis after prosthetic mitral valve replacement: a postoperative monocentric study of 680 patients. J Am Coll Cardiol 43:1283-90.nLin SS, Tiong IY, Asher CR, Murphy MT, Thomas JD, Griffin BP. 2000. Prediction of thrombus-related mechanical prosthetic valve dysfunction using transesophageal echocardiography. Am J Cardiol 6:1097-101.nMassel D, Little SH. 2001. Risks and benefits of adding anti-platelet therapy to warfarin among patients with prosthetic heart valves: a meta-analysis. J Am Coll Cardiol 37:569-78.nMirode A, Tribouilloy C, Adam MC, Kacem LH, Rey JL, Lesbre JP. 1993. Contribution of transesophageal ultrasonography in the etiologic evaluation of a systemic embolic accident. Apropos of 451 patients [article in French]. Arch Mal Coeur Vaiss 86:1701-8.nMitusch R, Doherty C, Wucherpfennig H, et al. 1997. Vascular events during follow-up in patients with aortic arch atherosclerosis. Stroke 28:36-9.nMontorsi P, De Bernardi F, Muratori M, Cavoretto D, Pepi M. 2000. Role of cine-fluoroscopy, transthoracic, and transesophageal echocardiography in patients with suspected prosthetic heart valve thrombosis. Am J Cardiol 85:58-64.nMügge A, Daniel WG, Haverich A, Lichtlen PR. 1991. Diagnosis of noninfective cardiac mass lesions by two-dimensional echocardiography: comparison of the transthoracic and transesophageal approaches. Circulation 83:70-8.nPaemelaère JM, Sirinelli A, Dreyfus X, Maillard L, Pottier JM, Raynaud P. 1996. Transesophageal echography and systemic ischemic incidences: 235 cases [article in French]. Rev Neurol (Paris) 152:27-31.nPearson AC, Labovitz AJ, Tatineni S, Gomez CR. 1991. Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology. J Am Coll Cardiol 17:66-72.nRoijer A, Lindgren A, Rudling O, et al. 1996. Potential cardioembolic sources in an elderly population without stroke. A transthoracic and transesophageal echocardiographic study in randomly selected volunteers. Eur Heart J 17:1103-11.nRoudaut R, Lafitte S, Roudaut MF, et al. 2003. Fibrinolysis of mechanical prosthetic valve thrombosis: a single-center study of 127 cases. J Am Coll Cardiol 41:653-8.nRoudaut R, Roques X, Lafitte S, et al. 2003. Surgery for prosthetic valve obstruction. A single center study of 136 patients. Eur J Cardiothorac Surg 24:868-72.nSchwartzbard A, Freedberg RS, Kronzon I. 2000. The value of repeat transesophageal echocardiography in the evaluation of embolism from the aorta. J Am Soc Echocardiogr 13:1124-6.nShapira Y, Herz I, Vaturi M, et al. 2000. Thrombolysis is an effective and safe therapy in stuck bileaflet mitral valves in the absence of high-risk thrombi. J Am Coll Cardiol 35:1874-80.nSimons AJ, Carlson R, Hare CL, Obeid AI, Smulyan H. 1992. The use of transesophageal echocardiography in detecting aortic atherosclerosis in patients with embolic disease. Am Heart J 123:224-6.nStoddard MF, Dawkins PR, Price CR, Ammash NM. 1995. Left atrial appendage thrombus is not uncommon in patients with acute atrial fibrillation and a recent embolic event: a transesophageal echocardiographic study. J Am Coll Cardiol 25:452-9.nThe French Study of Aortic Plaques in Stroke Group. 1996. Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke. N Engl J Med 334:1216-21.nTong AT, Roudaut R, Ozkan M, et al. 2004. Transesophageal echocardiography improves risk assessment of thrombolysis of prosthetic valve thrombosis: results of the international PRO-TEE registry. J Am Coll Cardiol 43:77-84.nTsai LM, Chen JH, Lin LJ, Teng JK. 1997. Natural history of left atrial spontaneous echo contrast in nonrheumatic atrial fibrillation. Am J Cardiol 80:897-900.nVandenbogaerde J, De Bleecker J, Decoo D, et al. 1992. Transesophageal echo-Doppler in patients suspected of a cardiac source of peripheral emboli. Eur Heart J 13:88-94.n



How to Cite

Maciejewski, M., Piestrzeniewicz, K., Jaszewski, R., Bielecka-Dabrowa, A., & Goch, J. H. (2011). Sources of Thromboembolism in Patients with Correctly Functioning Mechanical Valves: A Single-Center Transesophageal Echocardiographic Study. The Heart Surgery Forum, 14(3), E149-E156.