Management of Prosthetic Valve Thrombosis Complicated with Coronary Embolism

Management

of

Prosthetic

Valve

Thrombosis

Complicated

with

Coronary

Embolism

DearEditor,

Wehaverecentlyreadwithgreatinteresttheclinical

spot-lightbySousaetal.describingtheconservativemanagement

ofanobstructiveprostheticaorticvalvethrombosis

compli-catedbycoronaryembolism(CE)[1].Thankstotheauthors

fortheircontributionofthepresentreportincludingarare

complication ofprosthetic valvethrombosis. On the other

hand,wewanttomakeessentialcriticismsregardingsome

majordrawbacksinthemanagementofthepatient.

Coronaryembolismisararecauseofacutecoronary

syn-drome(ACS) inpatients with prosthetic heartvalves. The

majority ofpatients with prosthetic heartvalves admitted

withACSwerereportedtobenon-STelevationratherthan

STsegmentelevationACS[2].Thedataregardingthis

com-plication is scarce and mainly based on case reports. A

controversyexistswithregard tothetreatmentofpatients

withCE.Inthecurrentliterature,intracoronary

thromboly-sis, stent implantation and embolectomy have been

per-formedas reperfusionstrategies,butthereisnoconsensus

regardingtheoptimaltreatment.

Inthepresentcase,a38-year-oldmanwithbileaflet

mechan-icalaorticprosthesiswasadmittedwithnon-STelevationACS.

Accordingtothepatient’shistory,hehaddiscontinuedoral

anticoagulationwithwarfarinandinternationalnormalised

ratioonadmissionwassubtherapeutic.Transthoracic

echo-cardiography(TTE)revealednormallyfunctioningprosthesis

withnormaltransvalvulargradientsandeffectiveorificearea.

Subsequently,coronaryangiography(CAG)wasperformed

whichshowedembolicsubocclusioninthedistalsegmentof

theanteriordescendingartery.

The major concern regarding the management of this

patient is the use of TTE, which is usually incapable of

demonstrating the presence of non-obstructive thrombus

on the prosthetic valves, necessitating transoesophageal

echocardiographic (TEE) examination. Since the patient

had aortic prosthesis, urgent conventional CAG without

TEEexaminationmaycarryahighriskofthromboembolism

due to catheter manipulation during CAG. Although the

patientwas not complicated with new thromboembolism,

itwouldhavebeenbetterifCAGhadbeenperformedjust

afterTEEfindingsforsafecatheter intervention.

Anothernoteworthyissueregardingthemanagementofthe

patientisthat,prostheticvalvethrombosis(PVT)and

subse-quentCEasacomplicationshouldhavebeensuspectedon

admissionbasedontheclinicalfindings.Althoughthepatient

wasadmittedwithnon-STelevationACS,TTEshowed

seg-mentalwallmotionabnormalitiesandCAGrevealedembolic

subocclusioninthedistalsegmentoftheanteriordescending

artery.At thispoint thrombolytictherapy (TT)could have

beenabetterchoiceratherthandischargingthepatientunder

optimisedmedication.Insuchcases,ifACSwasconsideredto

bederivedfromPVT-relatedembolism,TTmightbe

consid-ered forthe managementofPVT inthe absenceof

contra-indications.Thefreshnatureoftheembolicthrombuscouldbe

associatedwiththesuccessfuloutcomesofTT.Inourrecently

publishedcaseseriesTTwassuccessfullyperformedinthe

managementofbothPVTandrelatedCE[3].

Prostheticvalvethrombosisisoneofthemajorcausesof

primaryvalvefailure.Treatmentmodalitiesincludeheparin

treatment,TTandsurgery.GuidelineslackdefinitiveclassI

recommendationsduetothelackofrandomisedcontrolled

trials,andusuallyleavethechoiceoftreatmenttothe

clini-cian’sexperience.Surgeryissuggestedasafirst-linestrategy

inmostsituationsofleft-sidedPVT;however,TThasbeen

recentlyusedwithsuccessfuloutcomes[4–6].Wehave

pre-viouslyreportedthatlowdose(25mg)andslowinfusion(six

hours) oft-PA is verysafe andassociated with very high

thrombolyticsuccessinthisregard[4,5].Moreverinarecent

meta-analysis,Castilhoetal.reportedmuchhighermortality

rateswith surgery comparedtoTTin themanagementof

PVT(18.1%vs.6.6%respectively)[7].

Asaresult,wecanconcludethatcoronary angiography

shouldbedeferreduntilafterTEEduetoriskof

thrombo-embolism during catheter manipulation in aortic PVT

patients who are admittedwith CE.Thrombolytictherapy

shouldbeconsideredasaninitialtreatmentmodalityinPVT

patients. Low dose and prolonged infusion of tPA is an

effective regimen which can be safely performed in the

absenceofcontraindications.

©2015AustralianandNewZealandSocietyofCardiacandThoracicSurgeons(ANZSCTS)andtheCardiacSocietyofAustraliaandNewZealand(CSANZ).PublishedbyElsevier Inc.Allrightsreserved.

Heart,LungandCirculation(2016)25,414–415 1443-9506/04/$36.00

http://dx.doi.org/10.1016/j.hlc.2015.05.027

Data

sharing

Noadditionaldata.

Contributorship

Alloftheauthorscontributedplanning,conduct,and

report-ing of the work. All contributors are responsible for the

overallcontentasguarantors.

Funding

Nofunding.

Competing

interests

Alloftheauthorshavenoconflictofinterest.

MacitKalc¸ık,MDa,*

MahmutYesin,MDb

MustafaOzanGu¨rsoy,MDc

Su¨leymanKarakoyun,MDd

Mehmet €Ozkan,MDb,e

a_{DepartmentofCardiology,I˙skilipAtıfHocaStateHospital,}

C¸orum,Turkey

b_{DepartmentofCardiology,KosuyoluKartalHeartTraining}

andResearchHospital,Istanbul,Turkey

c_{DepartmentofCardiology,GaziemirStateHospital,I˙zmir,}

Turkey d

DepartmentofCardiology,KarsKafkasUniversity,Facultyof

Medicine,Kars,Turkey

e

DivisionofHealthSciences,UniversityofArdahan,Ardahan,

Turkey *

Correspondingauthorat:I˙skilipAtıfHocaStateHospital,

C¸orum,Turkey,Address:MeydanMah.ToprakSok.

No:7/8I˙skilip,C¸orum/Turkey.Tel.:+(90)5364921789;

fax:+903645113187.

Email:[email protected](M.Kalc¸ık).

Received13November2014;receivedinrevisedform24

May2015;accepted28May2015;online

published-ahead-of-print15July2015

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