title: Bioprosthetic Valve Thrombosis Versus Structural Failure: Clinical and Echocardiographic Predictors.
abstract: BACKGROUND
  Bioprosthetic valve thrombosis (BPVT) is considered uncommon; this may be related to the fact that it is often unrecognized. Recent data suggest that BPVT responds to vitamin K antagonists, emphasizing the need for reliable diagnosis.
  
  
  OBJECTIVE
  This study sought to determine the diagnostic features of BPVT and to formulate a diagnostic model for BPVT.
  
  
  METHODS
  Cases of BPVT occurring between 1997 and 2013 were identified from the Mayo Clinic pathology database. Patients with BPVT were matched 1:2 for age, sex, and prosthesis position with patients whose valves were explanted for structural failure. We formulated a diagnostic model for BPVT using multivariate linear logistic regression and receiver operating characteristic.
  
  
  RESULTS
  Among 397 consecutive cases of explanted bioprostheses, there were 46 cases of BPVT (11.6%; aortic 29, mitral 9, tricuspid 7, pulmonary 1), mean age was 63 years, and 68% were male. Thirty (65%) cases occurred >12 months post-implantation; median bioprosthetic valve longevity was 24 months (cases) versus 108 months (controls) (p < 0.001). Independent predictors of BPVT were >50% increase in mean echo-Doppler gradient from baseline within 5 years (odds ratio [OR]: 12.7), paroxysmal atrial fibrillation (OR: 5.19), subtherapeutic international normalized ratio (OR: 7.37), increased cusp thickness (OR: 12.2), and abnormal cusp mobility (OR: 6.94). Presence of all 5 diagnostic features was predictive of BPVT with 76% sensitivity, 93% specificity, 85% positive predictive value, and 89% negative predictive value (p < 0.001).
  
  
  CONCLUSIONS
  BPVT is not uncommon and can occur several years after surgery. A combination of clinical and echocardiographic features can reliably diagnose BPVT.
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
authors.forename: Alexander C
authors.initials: AC
authors.lastname: Egbe
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota. Electronic address: pislaru.sorin@mayo.edu.
authors.forename: Sorin V
authors.initials: SV
authors.lastname: Pislaru
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Pellikka
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
authors.forename: Joseph T
authors.initials: JT
authors.lastname: Poterucha
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
authors.forename: Hartzell V
authors.initials: HV
authors.lastname: Schaff
authors.affiliation: Anatomic Pathology, Mayo Clinic, Rochester, Minnesota.
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Maleszewski
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
authors.forename: Heidi M
authors.initials: HM
authors.lastname: Connolly
mesh_terms: D000368:Aged; D001705:Bioprosthesis / Q000009:adverse effects* / Q000639:trends; D015331:Cohort Studies; D004452:Echocardiography / Q000639:trends; D005260:Female; D006331:Heart Diseases / Q000000981:diagnostic imaging* / Q000209:etiology; D006350:Heart Valve Prosthesis / Q000009:adverse effects* / Q000639:trends; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011475:Prosthesis Failure / Q000009:adverse effects* / Q000639:trends; D012189:Retrospective Studies; D013927:Thrombosis / Q000000981:diagnostic imaging* / Q000209:etiology
keywords: Doppler gradient; atrial fibrillation; cusp; valvular heart disease; vitamin K antagonist