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The leading role of thrombolysis in the management of prosthetic valve thrombosis
indian heart journal 68 (2016) 205–206
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/ihj
Research Letter
The leading role of thrombolysis in the management of prosthetic valve thrombosis
Keywords: Prosthetic valve thrombosis Echocardiography Thrombolysis
Dear Editor, We have recently read with great interest the editorial authored by Cáceres-Lóriga et al.1 The authors summarized the etiopathogenesis, diagnosis, and management of prosthetic valve thrombosis (PVT). We want to make several essential comments about the role of thrombolytic therapy (TT) in the management of PVT. Despite technological advancements, the hemodynamic and physical properties of mechanical valves remain thrombogenic and patients with prosthetic heart valves, therefore, are prone to developing PVT.2 There are different therapeutic modalities for PVT including anticoagulation with heparin, TT,3–6 and surgery7 which are largely influenced by the presence of valvular obstruction, by valve location, and by clinical features. Despite the improvement in mortality over the past decade, surgical management of PVT has been associated with a significant death risk for 40 years. Therefore, establishment of a more effective strategy to treat PVT is crucial, especially in the developing countries where this condition is prevalent.5 TT studies for PVT have shown much promise, with the results suggesting that such treatment modality might be the initial choice in these patients. Unfortunately, randomized controlled trials to address this management decision are lacking. Recently, several meta-analyses and systematic reviews have been published. Karthikeyan and colleagues8 evaluated seven studies with 690 episodes of PVT (446 treated with surgery and 244 with TT) and found no significant differences in the main outcome (restoration of valve functions) between patients treated surgically and TT. They stated that urgent surgery should probably be preferred over TT in experienced
centers. On the other hand, Castilho et al.7 reported much higher mortality rates with surgery compared with TT in the management of PVT (18.1% vs. 6.6%, respectively). Recently, our group5,6 has reported two studies which have shown the incremental role of TT in the management of PVT. The TROIA study5 which includes the largest cohort published to date, evaluated a strategy of transesophageal echocardiography (TEE)-guided fibrinolysis with rapid infusion of streptokinase (Group I) versus slow infusion of streptokinase (Group II) versus full-dose tissue plasminogen activator (t-PA) (100 mg) (Group III) versus half dose (50 mg) slow infusion of t-PA (Group IV) versus low dose (25 mg) slow infusion of t-PA (Group V). This was a monocentric, prospective, non-randomized study. The authors suggested that lower dose, TEE-guided, repeated, slow administration of a fibrinolytic agent could be equally efficacious with fewer complications. This was also confirmed in the PROMETEE trial6 which showed that ultra-slow (25 h) infusion of low dose (25 mg) t-PA without bolus was associated with quite low non-fatal complications and mortality for PVT patients except for those with NYHA class-IV, without compromising effectiveness. On the basis of these findings tPA, a fibrin-specific agent seems to be very effective.5,6 A similar benefit with intravenous bolus dose of tenecteplase has also been recently reported,9 but it should be acknowledged that although accelerated TT protocols may achieve more rapid lysis of the thrombus, they pose an essential risk for complications such as thromboembolism and hemorrhage. In TROIA study,5 the rate of intracranial bleed was 0.8% in PVT patients undergoing low-dose (t-PA strategy). In PROMETEE study,6 none of the patients suffered intracranial hemorrhage and the noncerebral major bleeding rate was also quite low (1.7%). As Cáceres-Lóriga et al.1 have stated in the present editorial, both transthoracic echocardiography and TEE are indispensable guides for evaluation of leaflet immobilization, cause of underlying pathology (thrombus versus pannus or both), and whether TT attempt in the patient would be successful or surgery is needed.10–12 These modalities enhance clinical decision making in patients with suspected PVT. Consequently, on the basis of recent evidences and our 20year experience, we think TT (slow-dose and prolonged infusion) under TEE guidance has proven its efficacy with a
206
indian heart journal 68 (2016) 205–206
good safety profile. Therefore, it should be considered as a first-line therapy in the management of PVT.
Conflicts of interest The authors have none to declare.
references
1. Cáceres-Lóriga FM, Morais H. Thrombotic obstruction in leftside prosthetic valves: role of thrombolytic therapy. Indian Heart J. 2015. http://dx.doi.org/10.1016/j.ihj. 2015.08.019. 2. Ozkan M, Gürsoy OM, Astarcıoğlu MA, et al. Real-time threedimensional transesophageal echocardiography in the assessment of mechanical prosthetic mitral valve ring thrombosis. Am J Cardiol. 2013;112:977–983. 3. Özkan M, Kaymaz C, Kırma C, et al. Intravenous thrombolytic treatment of mechanical prosthetic valve thrombosis: a study using serial transesophageal echocardiography. J Am Coll Cardiol. 2000;35:1881–1889. 4. Özkan M, Cakal B, Karakoyun S, et al. Thrombolytic therapy for the treatment of prosthetic heart valve thrombosis in pregnancy with low-dose, slow infusion of tissue-type plasminogen activator. Circulation. 2013;128:532–540. 5. Özkan M, Gunduz S, Biteker M, et al. Comparison of different TEE-guided thrombolytic regimens for prosthetic valve thrombosis: the TROIA trial. JACC Cardiovasc Imaging. 2013;6:206–216. 6. Özkan M, Gündüz S, Gürsoy OM, et al. A novel strategy in the management of PROsthetic Mechanical valve Thrombosis and the prEdictors of outcomE: the Ultra-slow PROMETEE trial. Am Heart J. 2015;170:409–418. 7. Castilho FM, De Sousa MR, Mendonça AL, et al. Thrombolytic therapy or surgery for valve prosthesis thrombosis: systematic review and meta-analysis. J Thromb Haemost. 2014;12:1218–1228. 8. Karthikeyan G, Senguttuvan NB, Joseph J, Devasenapathy N, Bahl VK, Airan B. Urgent surgery compared with fibrinolytic therapy for the treatment of left-sided prosthetic heart valve thrombosis: a systematic review and meta-analysis of observational studies. Eur Heart J. 2013;34:1557–1566. 9. Lahoti HA, Goyal BK. Successful use of tenecteplase in a patient with recurrence of prosthetic mitral valve thrombosis. Indian Heart J. 2015;67:S55–S57. http://dx.doi.org/ 10.1016/j.ihj.2015.08.031.
10. Ben Zekry S, Saad RM, Ozkan M, et al. Flow acceleration time and ratio of acceleration time to ejection time for prosthetic aortic valve function. JACC Cardiovasc Imaging. 2011;4: 1161–1170. 11. Gursoy OM, Ozkan M. The role of real-time 3-dimensional transesophageal echocardiography in depiction of the concealed base of the iceberg. Anadolu Kardiyol Derg. 2012;12: E22–E23. 12. Ozkan M, Gunduz S, Yildiz M, et al. Diagnosis of the prosthetic heart valve pannus formation with real-time three-dimensional transoesophageal echocardiography. Eur J Echocardiogr. 2010;11:E17.
Mustafa Ozan Gürsoy* Department of Cardiology, Gaziemir State Hospital, İzmir, Turkey Macit Kalçık Department of Cardiology, İskilip Atıf Hoca State Hospital, Çorum, Turkey Mahmut Yesin Department of Cardiology, Kars State Hospital, Kars, Turkey Süleyman Karakoyun Department of Cardiology, Kars Kafkas University, Faculty of Medicine, Kars, Turkey Mehmet Özkana,b Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey b School of Health Sciences, Ardahan University, Ardahan, Turkey a
*Corresponding author E-mail address: [email protected] (M.O. Gürsoy) Available online 12 January 2016 http://dx.doi.org/10.1016/j.ihj.2015.12.019 0019-4832/ # 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/ihj
Research Letter
The leading role of thrombolysis in the management of prosthetic valve thrombosis
Keywords: Prosthetic valve thrombosis Echocardiography Thrombolysis
Dear Editor, We have recently read with great interest the editorial authored by Cáceres-Lóriga et al.1 The authors summarized the etiopathogenesis, diagnosis, and management of prosthetic valve thrombosis (PVT). We want to make several essential comments about the role of thrombolytic therapy (TT) in the management of PVT. Despite technological advancements, the hemodynamic and physical properties of mechanical valves remain thrombogenic and patients with prosthetic heart valves, therefore, are prone to developing PVT.2 There are different therapeutic modalities for PVT including anticoagulation with heparin, TT,3–6 and surgery7 which are largely influenced by the presence of valvular obstruction, by valve location, and by clinical features. Despite the improvement in mortality over the past decade, surgical management of PVT has been associated with a significant death risk for 40 years. Therefore, establishment of a more effective strategy to treat PVT is crucial, especially in the developing countries where this condition is prevalent.5 TT studies for PVT have shown much promise, with the results suggesting that such treatment modality might be the initial choice in these patients. Unfortunately, randomized controlled trials to address this management decision are lacking. Recently, several meta-analyses and systematic reviews have been published. Karthikeyan and colleagues8 evaluated seven studies with 690 episodes of PVT (446 treated with surgery and 244 with TT) and found no significant differences in the main outcome (restoration of valve functions) between patients treated surgically and TT. They stated that urgent surgery should probably be preferred over TT in experienced
centers. On the other hand, Castilho et al.7 reported much higher mortality rates with surgery compared with TT in the management of PVT (18.1% vs. 6.6%, respectively). Recently, our group5,6 has reported two studies which have shown the incremental role of TT in the management of PVT. The TROIA study5 which includes the largest cohort published to date, evaluated a strategy of transesophageal echocardiography (TEE)-guided fibrinolysis with rapid infusion of streptokinase (Group I) versus slow infusion of streptokinase (Group II) versus full-dose tissue plasminogen activator (t-PA) (100 mg) (Group III) versus half dose (50 mg) slow infusion of t-PA (Group IV) versus low dose (25 mg) slow infusion of t-PA (Group V). This was a monocentric, prospective, non-randomized study. The authors suggested that lower dose, TEE-guided, repeated, slow administration of a fibrinolytic agent could be equally efficacious with fewer complications. This was also confirmed in the PROMETEE trial6 which showed that ultra-slow (25 h) infusion of low dose (25 mg) t-PA without bolus was associated with quite low non-fatal complications and mortality for PVT patients except for those with NYHA class-IV, without compromising effectiveness. On the basis of these findings tPA, a fibrin-specific agent seems to be very effective.5,6 A similar benefit with intravenous bolus dose of tenecteplase has also been recently reported,9 but it should be acknowledged that although accelerated TT protocols may achieve more rapid lysis of the thrombus, they pose an essential risk for complications such as thromboembolism and hemorrhage. In TROIA study,5 the rate of intracranial bleed was 0.8% in PVT patients undergoing low-dose (t-PA strategy). In PROMETEE study,6 none of the patients suffered intracranial hemorrhage and the noncerebral major bleeding rate was also quite low (1.7%). As Cáceres-Lóriga et al.1 have stated in the present editorial, both transthoracic echocardiography and TEE are indispensable guides for evaluation of leaflet immobilization, cause of underlying pathology (thrombus versus pannus or both), and whether TT attempt in the patient would be successful or surgery is needed.10–12 These modalities enhance clinical decision making in patients with suspected PVT. Consequently, on the basis of recent evidences and our 20year experience, we think TT (slow-dose and prolonged infusion) under TEE guidance has proven its efficacy with a
206
indian heart journal 68 (2016) 205–206
good safety profile. Therefore, it should be considered as a first-line therapy in the management of PVT.
Conflicts of interest The authors have none to declare.
references
1. Cáceres-Lóriga FM, Morais H. Thrombotic obstruction in leftside prosthetic valves: role of thrombolytic therapy. Indian Heart J. 2015. http://dx.doi.org/10.1016/j.ihj. 2015.08.019. 2. Ozkan M, Gürsoy OM, Astarcıoğlu MA, et al. Real-time threedimensional transesophageal echocardiography in the assessment of mechanical prosthetic mitral valve ring thrombosis. Am J Cardiol. 2013;112:977–983. 3. Özkan M, Kaymaz C, Kırma C, et al. Intravenous thrombolytic treatment of mechanical prosthetic valve thrombosis: a study using serial transesophageal echocardiography. J Am Coll Cardiol. 2000;35:1881–1889. 4. Özkan M, Cakal B, Karakoyun S, et al. Thrombolytic therapy for the treatment of prosthetic heart valve thrombosis in pregnancy with low-dose, slow infusion of tissue-type plasminogen activator. Circulation. 2013;128:532–540. 5. Özkan M, Gunduz S, Biteker M, et al. Comparison of different TEE-guided thrombolytic regimens for prosthetic valve thrombosis: the TROIA trial. JACC Cardiovasc Imaging. 2013;6:206–216. 6. Özkan M, Gündüz S, Gürsoy OM, et al. A novel strategy in the management of PROsthetic Mechanical valve Thrombosis and the prEdictors of outcomE: the Ultra-slow PROMETEE trial. Am Heart J. 2015;170:409–418. 7. Castilho FM, De Sousa MR, Mendonça AL, et al. Thrombolytic therapy or surgery for valve prosthesis thrombosis: systematic review and meta-analysis. J Thromb Haemost. 2014;12:1218–1228. 8. Karthikeyan G, Senguttuvan NB, Joseph J, Devasenapathy N, Bahl VK, Airan B. Urgent surgery compared with fibrinolytic therapy for the treatment of left-sided prosthetic heart valve thrombosis: a systematic review and meta-analysis of observational studies. Eur Heart J. 2013;34:1557–1566. 9. Lahoti HA, Goyal BK. Successful use of tenecteplase in a patient with recurrence of prosthetic mitral valve thrombosis. Indian Heart J. 2015;67:S55–S57. http://dx.doi.org/ 10.1016/j.ihj.2015.08.031.
10. Ben Zekry S, Saad RM, Ozkan M, et al. Flow acceleration time and ratio of acceleration time to ejection time for prosthetic aortic valve function. JACC Cardiovasc Imaging. 2011;4: 1161–1170. 11. Gursoy OM, Ozkan M. The role of real-time 3-dimensional transesophageal echocardiography in depiction of the concealed base of the iceberg. Anadolu Kardiyol Derg. 2012;12: E22–E23. 12. Ozkan M, Gunduz S, Yildiz M, et al. Diagnosis of the prosthetic heart valve pannus formation with real-time three-dimensional transoesophageal echocardiography. Eur J Echocardiogr. 2010;11:E17.
Mustafa Ozan Gürsoy* Department of Cardiology, Gaziemir State Hospital, İzmir, Turkey Macit Kalçık Department of Cardiology, İskilip Atıf Hoca State Hospital, Çorum, Turkey Mahmut Yesin Department of Cardiology, Kars State Hospital, Kars, Turkey Süleyman Karakoyun Department of Cardiology, Kars Kafkas University, Faculty of Medicine, Kars, Turkey Mehmet Özkana,b Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey b School of Health Sciences, Ardahan University, Ardahan, Turkey a
*Corresponding author E-mail address: [email protected] (M.O. Gürsoy) Available online 12 January 2016 http://dx.doi.org/10.1016/j.ihj.2015.12.019 0019-4832/ # 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.