Title : Thrombus formation on a tricuspid annuloplasty ring: A rare complication
Abstract:
Introduction: Prosthetic ring annuloplasty is a standard technique for tricuspid valve repair. According to current guidelines, vitamin K antagonists should be considered for 3 months after surgical intervention, however robust evidence for this practice remains scarce. Tricuspid ring thrombosis after intervention is a rare complication, and it is influenced by multiple predisposing factors, including the undersizing of the valve ring, which may contribute to stasis.
Clinical Case: A 64-year-old male presented with an ostium secundum atrial septal defect associated with an aneurysmatic interauricular septum (total excursion 20 mm), characterized by multiple fenestrations with three communications and a severe left-to-right shunt, leading to an unsuitable percutaneous closure. Additional findings included an aneurysmatic interventricular septum at the membranous portion that had most likely suffered a spontaneous closure; moderate to severe mitral regurgitation; and tricuspid annular dilation (43 mm) with minimal tricuspid regurgitation. The patient underwent surgical repair, with closure of the interatrial defect using autologous pericardium and tricuspid annuloplasty with nº 32 Sovering ring. After intervention, the patient was anticoagulated for 3 months and remained asymptomatic. Transthoracic echocardiogram at the postoperative 6 months follow-up demonstrated successful closure of the atrial septal defect without residual shunting. However, it also revealed moderate restriction in tricuspid valve opening (maximum transvalvular gradient of 27 mmHg and mean gradient of 13 mmHg) and a bilobed mass (23 x 6 mm) on the atrial surface of the non-septal tricuspid leaflet, protruding into the ventricle during diastole. The patient was hospitalized and re-initiated on anticoagulation therapy. A transesophageal echocardiogram confirmed the existence of a bilobed mass with 20 x 7 mm and 12 x 9 mm in its respective components. Despite the findings, the patient remained asymptomatic with no constitutional symptoms, negative blood cultures, normal inflammatory parameters and no evidence of embolic events on a full-body CT scan. A multidisciplinary Heart Team reviewed the case, and the diagnosis of thrombus was deemed more likely. Prothrombotic study was conducted and re-evaluation with transesophageal echocardiogram was scheduled before discharge.
Conclusion: Thrombus formation after tricuspid valve repair is an uncommon but significant complication. The limited evidence regarding optimal anticoagulation strategies in this population underscores the need for personalized management according to individual patient profile in the clinical practice. Various factors may contribute to thrombus formation, highlighting the critical role of a multidisciplinary approach in ensuring comprehensive evaluation and effective management of these patients.
