Evaluation of Thromboembolism and Valve Thrombosis in Patients with Rheumatic Heart Disease Undergoing Mitral Tissue Valve Replacement in the Presence of Atrial Fibrillation with or without Left Atrial Clot: Review of A 17-Years’ Experience

Ujjwal Kumar Chowdhury, Adil Rizvi, Lakshmi Kumari Sankhyan, Suruchi Hasija, Kartik Patel, Sandeep Seth, Abhinavsingh Chauhan and Mani Kalaivani

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, India
Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, India
Department of Biostatistics, All India Institute of Medical Sciences, India

^*Correspondance to: Ujjwal Kumar Chowdhury 

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Abstract:

Background and
Aim: To evaluate the incidence of thromboembolism in patients implanted with tissue mitral valves and to evaluate the risks and benefits of left atrial appendage ligation.
Materials and Methods: Carpentier-Edwards perimount, pericardial bioprostheses were implanted in 168 consecutive patients between January 2000 and March 2017 in the mitral position due to rheumatic heart disease. The patient’s ages ranged between 12 and 75 years (mean ± SD 34.2 ± 9.8 years). Sixty-eight (40.4%) patients had giant left atrium measuring more than 65 mm diameter. Sixty (35.7%) patients underwent surgical reduction of giant left atrium. The left atrial appendage was ligated in 110 (65.5%) patients.
Results: The hospital and late mortalities were 1.8% and 1.8% respectively. The total cumulative follow-up period was 1447.2 patient-years with a mean of 107.2 ± 56.4 months (range, 1-207 months). There were 7 events of thromboembolism (2 events per 100 patient-years) and two instances of left atrial clot requiring re-institution of warfarin therapy. The actuarial survival and actuarial event-free survival at 207 months was 95.04% (± 0.02%) and 88.1% (± 0.04%) respectively.
Conclusion: We conclude that anticoagulation may be discontinued after 3 months in the majority of patients undergoing bioprosthetic MVR. Low intensity anticoagulation with an INR between 1.5 and 2.0 should be continued lifelong in a select subset of patients with preoperative atrial fibrillation, thromboembolism, giant left atrium, and low left ventricular ejection fraction and bioprosthetic degeneration. Liberal left atrial appendage ligation and surgical reduction of giant left atrium during MVR is consistent with reduction of surgical mortality, low cardiac output syndrome, respiratory complications and risk of late systemic embolism.

Keywords:

Mitral valve replacement; Carpentier-Edwards pericardial prosthesis; Bioprosthetic degeneration; Thromboembolism; Left atrial appendage

Cite the Article:

Chowdhury UK, Rizvi A, Sankhyan LK, Hasija S, Patel K, Seth S, et al. Evaluation of Thromboembolism and Valve Thrombosis in Patients with Rheumatic Heart Disease Undergoing Mitral Tissue Valve Replacement in the Presence of Atrial Fibrillation with or without Left Atrial Clot: Review of A 17-Years’ Experience. World J Surg Surgical Res. 2018; 1: 1042.