The leading role of thrombolysis in the management of prosthetic valve thrombosis

Research

Letter

The

leading

role

of

thrombolysis

in

the

management

of

prosthetic

valve

thrombosis

DearEditor,

We have recently read with great interest the editorial

authoredbyCáceres-Lórigaetal.1Theauthorssummarized

the etiopathogenesis, diagnosis,and management of

pros-thetic valve thrombosis (PVT). We want to make several

essentialcomments aboutthe roleof thrombolytictherapy

(TT)inthemanagementofPVT.

Despite technological advancements, the hemodynamic

andphysicalpropertiesofmechanicalvalvesremain

thrombo-genicandpatientswithprostheticheartvalves,therefore,are

prone to developing PVT.2 _{There are different therapeutic}

modalities for PVT including anticoagulation with heparin,

TT,3–6andsurgery7whicharelargelyinfluencedbythepresence

of valvular obstruction, by valve location, and by clinical

features.

Despitetheimprovementinmortalityoverthepastdecade,

surgical management of PVT has been associated with a

significantdeathriskfor40years.Therefore,establishmentof

amoreeffectivestrategytotreatPVTiscrucial,especiallyin

thedevelopingcountrieswherethisconditionisprevalent.5

TTstudiesforPVThaveshownmuchpromise,withtheresults

suggestingthatsuchtreatmentmodalitymightbetheinitial

choice in these patients. Unfortunately, randomized

con-trolledtrialstoaddressthismanagementdecisionarelacking.

Recently, several meta-analyses and systematic reviews

havebeenpublished.Karthikeyanandcolleagues8_evaluated

seven studies with 690 episodes of PVT (446 treated with

surgeryand244withTT)andfoundnosignificantdifferences

inthemainoutcome(restorationofvalvefunctions)between

patientstreatedsurgically and TT.They stated thaturgent

surgeryshouldprobablybepreferredoverTTinexperienced

centers. On theother hand, Castilho et al.7 _reportedmuch

highermortalityrateswithsurgerycomparedwithTTinthe

managementofPVT(18.1%vs.6.6%,respectively).Recently,

ourgroup5,6_{hasreportedtwostudieswhichhaveshownthe}

incrementalroleofTTinthemanagementofPVT.

The TROIA study5 _{which includes the largest cohort}

published to date, evaluated a strategy of transesophageal

echocardiography(TEE)-guidedfibrinolysiswithrapidinfusion

ofstreptokinase(GroupI)versusslowinfusionofstreptokinase

(GroupII)versusfull-dosetissueplasminogenactivator(t-PA)

(100mg)(GroupIII)versushalfdose(50mg)slowinfusionof

t-PA(GroupIV)versuslowdose(25mg)slowinfusionoft-PA

(GroupV).Thiswasamonocentric,prospective,

non-random-izedstudy.Theauthorssuggestedthatlowerdose,TEE-guided,

repeated,slowadministrationofafibrinolyticagentcouldbe

equally efficacious with fewer complications. This was also

confirmedinthePROMETEEtrial6_{whichshowedthatultra-slow}

(25h) infusion of low dose (25mg) t-PA without bolus was

associatedwithquitelownon-fatalcomplicationsand

mortali-tyforPVTpatientsexceptforthosewithNYHAclass-IV,without

compromisingeffectiveness.OnthebasisofthesefindingstPA,

afibrin-specificagentseemstobeveryeffective.5,6_Asimilar

benefitwithintravenousbolusdoseoftenecteplasehasalso

beenrecentlyreported,9_{butit shouldbe acknowledgedthat}

althoughacceleratedTTprotocolsmayachievemorerapidlysis

ofthethrombus,theyposeanessentialriskforcomplications

suchasthromboembolismandhemorrhage.InTROIAstudy,5

the rate of intracranial bleed was 0.8% in PVT patients

undergoinglow-dose(t-PAstrategy).InPROMETEEstudy,6none

ofthepatientssufferedintracranialhemorrhageandthe

non-cerebralmajorbleedingratewasalsoquitelow(1.7%).

As Cáceres-Lóriga et al.1 _{have stated in the present}

editorial, both transthoracicechocardiography and TEE are

indispensableguidesforevaluationofleafletimmobilization,

cause of underlyingpathology(thrombusversus pannusor

both), and whether TT attempt in the patient would be

successfulorsurgeryisneeded.10–12Thesemodalitiesenhance

clinicaldecisionmakinginpatientswithsuspectedPVT.

Consequently,onthebasisofrecentevidencesandour

20-year experience, we think TT (slow-dose and prolonged

infusion)underTEEguidancehasprovenitsefficacywitha

indianheartjournal68(2016) 205–206

Keywords:

Prostheticvalvethrombosis

Echocardiography Thrombolysis

Available

online

at

www.sciencedirect.com

ScienceDirect

good safetyprofile.Therefore, it shouldbeconsideredas a

first-linetherapyinthemanagementofPVT.

Conflicts

of

interest

Theauthorshavenonetodeclare.

r

e

f

e

r

e

n

c

e

s

1. Cáceres-LórigaFM,MoraisH.Thromboticobstructionin

left-sideprostheticvalves:roleofthrombolytictherapy.Indian

HeartJ.2015.http://dx.doi.org/10.1016/j.ihj.2015.08.019.

2. OzkanM,GürsoyOM,AstarcıoğluMA,etal.Real-time three-dimensionaltransesophagealechocardiographyinthe assessmentofmechanicalprostheticmitralvalvering thrombosis.AmJCardiol.2013;112:977–983.

3. ÖzkanM,KaymazC,KırmaC,etal.Intravenous thrombolytictreatmentofmechanicalprostheticvalve thrombosis:astudyusingserialtransesophageal echocardiography.JAmCollCardiol.2000;35:1881–1889.

4. ÖzkanM,CakalB,KarakoyunS,etal.Thrombolytictherapy forthetreatmentofprostheticheartvalvethrombosisin pregnancywithlow-dose,slowinfusionoftissue-type plasminogenactivator.Circulation.2013;128:532–540.

5. ÖzkanM,GunduzS,BitekerM,etal.Comparisonofdifferent TEE-guidedthrombolyticregimensforprostheticvalve thrombosis:theTROIAtrial.JACCCardiovascImaging. 2013;6:206–216.

6. ÖzkanM,GündüzS,GürsoyOM,etal.Anovelstrategyinthe managementofPROstheticMechanicalvalveThrombosis andtheprEdictorsofoutcomE:theUltra-slowPROMETEE trial.AmHeartJ.2015;170:409–418.

7. CastilhoFM,DeSousaMR,MendonçaAL,etal.Thrombolytic therapyorsurgeryforvalveprosthesisthrombosis: systematicreviewandmeta-analysis.JThrombHaemost. 2014;12:1218–1228.

8. KarthikeyanG,SenguttuvanNB,JosephJ,DevasenapathyN, BahlVK,AiranB.Urgentsurgerycomparedwithfibrinolytic therapyforthetreatmentofleft-sidedprostheticheartvalve thrombosis:asystematicreviewandmeta-analysisof observationalstudies.EurHeartJ.2013;34:1557–1566.

9. LahotiHA,GoyalBK.Successfuluseoftenecteplaseina

patientwithrecurrenceofprostheticmitralvalve

thrombosis.IndianHeartJ.2015;67:S55–S57.http://dx.doi.org/

10.1016/j.ihj.2015.08.031.

10. BenZekryS,SaadRM,OzkanM,etal.Flowaccelerationtime andratioofaccelerationtimetoejectiontimeforprosthetic aorticvalvefunction.JACCCardiovascImaging.2011;4: 1161–1170.

11. GursoyOM,OzkanM.Theroleofreal-time3-dimensional transesophagealechocardiographyindepictionofthe concealedbaseoftheiceberg.AnadoluKardiyolDerg.2012;12: E22–E23.

12. OzkanM,GunduzS,YildizM,etal.Diagnosisofthe prostheticheartvalvepannusformationwithreal-time three-dimensionaltransoesophagealechocardiography.Eur JEchocardiogr.2010;11:E17.

MustafaOzanGürsoy*

DepartmentofCardiology,GaziemirStateHospital,İzmir,Turkey

MacitKalçık

DepartmentofCardiology,İskilipAtıfHocaStateHospital,

Çorum,Turkey

MahmutYesin

DepartmentofCardiology,KarsStateHospital,Kars,Turkey

SüleymanKarakoyun

DepartmentofCardiology,KarsKafkasUniversity,Facultyof

Medicine,Kars,Turkey

MehmetÖzkana,b

a_{DepartmentofCardiology,KosuyoluKartalHeartTrainingand}

ResearchHospital,Istanbul,Turkey

b_{SchoolofHealthSciences,ArdahanUniversity,Ardahan,Turkey}

*Correspondingauthor

E-mailaddress:m.ozangursoy@yahoo.com(M.O.Gürsoy)

Availableonline12January2016

http://dx.doi.org/10.1016/j.ihj.2015.12.019

0019-4832/

#2015CardiologicalSocietyofIndia.PublishedbyElsevierB.V.

Allrightsreserved.

indianheart journal68(2016) 205–206