Letter
to
the
Editor
Recently
introduced
thrombolytic
therapy
regimens
have
been
suf
ficiently
effective
and
safer
in
patients
with
prosthetic
valve
thrombosis
TotheEditor,
We have read with great interest the article by Araiza-Garaygordobilet?al.entitled “Thrombolytictreatment foracute prostheticvalvethrombosis:Isit betterthansurgery?”[1].?The authors reported a case of mitral prosthetic valve thrombosis (PVT),whichwassuccessfullytreatedwithanintravenousbolusof 15mg tissue type plasminogen activator (t-PA)and continuous infusionof85mgt-PAfor90min.Wecongratulatetheauthorsfor achieving a successful outcome in such a high-risk patient. However,wewouldliketocontributetothecasereportdiscussing thenewlow-doseslow-infusionthrombolytictherapy(TT) regi-menswhichhavebeenassociatedwithlowercomplicationrates. TThasincreasinglybecomeanalternativetosurgeryasa first-linetherapyinpatientswithPVT.Weagreewiththeauthorsthat TTprovides theadvantageofwidespreadavailabilityandeasier administrationascomparedtosurgery[2].?However,standardTT regimens withaccelerated and highdose t-PA (as used in the presentcase)maystillbeassociatedwithhighercomplicationand mortality rates. Recently, several trials have been reported regardingthesafetyandefficacyofTTregimens withlow-dose andslow-infusionoft-PA[2].?InTROIATrial,lowdose(25mg)– slowinfusion (6h) of t-PA hasbeen foundto bea sufficiently effectiveandsaferregimeninthemanagementofPVTascompared withhigherdoseandfastinfusionregimens[3].?The2017?AHA/ ACC Focused Update of the 2014?AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease now recommendsurgentinitial treatment witheither slow-infusion low-doseTToremergencysurgeryforobstructivePVTasfirst-line treatmentstrategieswithclass1Bindication[4].?Theultra-slow PROMETEETrialhasdemonstratedthatultra-slow(25h)infusion oflow-dose(25mg)t-PAwithoutbolusappearstobeassociated withlower non-fatalcomplicationsand mortalityratesfor PVT patientswithoutlossofeffectiveness[5].
Inconclusion,lowfatalandnon-fatalcomplicationrateswith low-doseandslow/ultraslowinfusionTTregimensstrengthenthe handofTTagainstsurgery.Cliniciansshouldpreferevidence-based treatmentsandavoid overuseof regimensbeyond thereported safetymeasures.
Conflictofinterest
Theauthorsdeclarethattheyhavenoconflictofinterest.
Funding
Thismanuscriptwasnotfunded. References
[1]Araiza-GaraygordobilD,Aguilar-RojasLA,Mendoza-Garcı´aS,Barajas-Campos
RL,Casal-AlonsoS,Brisen˜ o-de-la-CruzJL,etal.Thrombolytictreatmentfor
acuteprostheticvalvethrombosis:isitbetterthansurgery.JCardiolCases
2017;16:162–4.
[2]GunerA,KalcikM,GursoyMO,GunduzS,OzkanM.Howto performand
managelow-doseandslow/ultra-slowtissuetypeplasminogenactivator
infu-sionregimensinpatientswithprostheticvalvethrombosis.JThromb
Throm-bolysis2018;46:399–402.
[3]€yzkanM,Gu¨ndu¨z S,BitekerM,AstarciogluMA, €yevikC, KaynakE,etal.
ComparisonofdifferentTEE-guidedthrombolyticregimensforprostheticvalve
thrombosis:theTROIAtrial.JACCCardiovascImaging2013;6:206–16.
[4]NishimuraRA,OttoCM,BonowRO,CarabelloBA,Erwin3rdJP,FleisherLA,etal.
2017?AHA/ACCfocusedupdateofthe2014?AHA/ACCguidelineforthe
man-agementofpatientswithvalvularheartdisease:areportoftheAmerican
CollegeofCardiology/AmericanHeartAssociationTaskForceonClinical
Prac-ticeGuidelines.JAmCollCardiol2017;70:252–89.
[5]€yzkanM,Gu¨ndu¨zS,Gu¨rsoyOM,KarakoyunS,AstarcoluMA,Kalc¸kM,etal.Ultra
slowthrombolytictherapy:anovelstrategyinthemanagementofPROsthetic
MEchanicalvalveThrombosisandtheprEdictorsofoutcomE:theultra-slow
PROMETEEtrial.AmHeartJ2015;170:409–18.
AhmetGuner(MD)*
KosuyoluKartalHeartTrainingandResearchHopital,Istanbul,Turkey MacitKalcik(MD) DepartmentofCardiology,FacultyofMedicine,HititUniversity, Corum,Turkey SabahattinGunduz(MD) DepartmentofCardiology,VMMedikalParkPendikHospital,Istanbul, Turkey
MehmetOzkan(MD)ab
a
KosuyoluKartalHeartTrainingandResearchHopital,Istanbul, Turkey
bSchoolofHealthSciences,ArdahanUniversity,Ardahan,Turkey
*Correspondingauthorat:DepartmentofCardiology,Kosuyolu KartalHeartTraining&ResearchHospital,CevizliMah,DenizerCad. CevizliKavag,34865?Kartal/_Istanbul,Turkey E-mailaddress:ahmetguner489@gmail.com(A.Guner).
JournalofCardiologyCases19(2019)74
ContentslistsavailableatScienceDirect
Journal
of
Cardiology
Cases
j our na l h ome p a ge : w ww . e l se v i e r. co m/ l oc a te / j c ca se
https://doi.org/10.1016/j.jccase.2018.11.002
