Thrombolytic therapy as first line treatment in prosthetic mitral valve thrombosis
Keywords:Prosthetic valve thrombosis , Transthoracic echocardiography, Transoesophageal echocardiography, Streptokinase, Urokinase
Background: A very common post-operative mechanical complication of a prosthetic valve is thrombosis leading to valve being stuck. This leads to rapid development of heart failure and can result in sudden death of the patient in an aggravated manner. The study aims to put forth the importance of immediate thrombolysis in such patients which can provide bridging between the event and immediate surgery.
Methods: A total of 50 patients were retrospectively studied after presentation with prosthetic valve thrombosis and the thrombolytic agent used in all the cases was injectable streptokinase or urokinase. Post streptokinase patients were given heparin infusion and oral anticoagulants. The therapy was considered failure if transvalvular gradients decreased less than 50% or in case of persistent valve motion abnormality.
Results: 94% patients had complete normalisation of valve function and decrease in transvalvular gradients to less than 50% within the first 24 hours. 4% patients required surgery and 2% patients could not survive the treatment.
Conclusions: Immediate thrombolysis on presentation has shown significant improvement in survival without the risk of subjecting patients to redo surgeries which are associated with multiple complications in the perioperative period.
Cannegieter SC, Rosendaal FR. Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation. 1994;89:635-41.
Thorburn CW, Morgan JJ, Shanahan MX, Chang VP. Long-term results of tricuspid valve replacement and the problem of the prosthetic valve thrombosis. Am J Cardiol. 1983;51:1128-3.
Roudaut R, Labbe T, Lorient-Roudaut MF, Gosse P, Baudet E, Fontan F, et al. Mechanical cardiac valve thrombosis. Is fibrinolysis justified? Circulation. 1992;86(5):II8-15.
Nagy A, Denes M, Lengyel M. Predictors of the outcome of thrombolytic therapy in prosthetic mitral valve thrombosis: a study of 62 events. J Heart Valve Dis. 2009;18:268-75.
Duran NE, Biteker M, Ozkan M. Treatment alternatives in mechanical valve thrombosis. Turk Kardiyol Dern Ars. 2008;36(6):420-5.
Grunkemeier GL, Li HH, Naftel DC, Starr A, Rahimtoola SH. Long-term performance of heart valve prostheses. Curr Probl Cardiol. 2000;25(2):78-7.
Vongpatanasin W, Hillis LD, Lange RA. Prosthetic heart valves. N Engl J Med. 1996;335:407-16.
Kontos Jr GJ, Schaff HV, Orszulak TA, Puga FJ, Pluth JR, Danielson GK. Thrombotic obstruction of disc valves: clinical recognition and surgical management. Annal Thorac Surg. 1989;48(1):60-5.
Patil SN, Ramalingam R, Rudrappa MMB, Manjunath CN. Study of prosthetic heart valve thrombosis and outcomes after thrombolysis. Int J Res Med Sci. 2019;7:1074-8.
Gupta D, Kothari SS, Bahl VK, Goswami KC, Talwar KK, Manchanda SC, et al. Thrombolytic therapy for prosthetic valve thrombosis: short-and long-term results. Am Heart J. 2000;140:906-16.
Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, Grayburn PA, et al. Recommendations for evaluation of prosthetic valves with echocardiography and Doppler ultrasound. J Am Soc Echocardiogr. 2009;22:975-1014.
Tong AT, Roudaut R, Ozkan M, Sagie A, Shahid MS, Pontes Júnior SC, et al. Transesophageal echocardiography improves risk assessment of thrombolysis of prosthetic valve thrombosis: Results of the international PRO-TEE registry. J Am Coll Cardiol. 2004;43:77-84.
Ueda T, Teshima H, Fukunaga S, Aoyagi S, Tanaka H. Evaluation of prosthetic valve obstruction on electrocardiographically gated multidetector row computed tomography – Identification of subprosthetic pannus in the aortic position. Circ J. 2013;77:418-23.
Tanis W, Habets J, van den Brink RB, Symersky P, Budde RP, Chamuleau SA. Differentiation of thrombus from pannus as the cause of acquired mechanical prosthetic heart valve obstruction by non-invasive imaging: A review of the literature. Eur Heart J Cardiovasc Imaging. 2014;15:119-29.
Kapos I, Fuchs T, Tanner FC. Case report of successful low-dose, ultra-slow infusion thrombolysis of prosthetic mitral valve thrombosis in a high-risk patient after redo-mitral valve replacement. Eur Heart J Case Rep. 2020;4(3):1-5.
Dangas GD, Weitz JI, Giustino G, Makkar R, Mehran R. Prosthetic heart valve thrombosis. J Am Coll Cardiol. 2016;68(24):2670-89.
Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143(5):e35-71.
Krishnan S. Prosthetic heart valve thrombosis: Diagnosis and newer thrombolytic regimes. J Pract Cardiovasc Sci. 2016;2:7-12.
Castilho FM, De Sousa MR, Mendonca AL, Ribeiro AL, Cáceres-Lóriga FM. Thrombolytic therapy or surgery for valve prosthesis thrombosis: Systematic review and meta-analysis. Thromb Haemost. 2014;12:1218-28.
Caceres-Loriga FM, Perez-Lopez H, Morlans-Hernandez K, Facundo-Sanchez H, Santos-Gracia J, Valiente-Mustelier J, et al. Thrombolysis as first choice therapy in prosthetic heart valve thrombosis. A study of 68 patients. J Thromb Thrombolysis. 2006;21(2):185-90.
Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J. 2012;33(19):2451-96.
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, et al. 2014 AHA/ ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):e57-85.
Birdi I, Angelini GD, Bryan AJ. Thrombolytic therapy for left-sided prosthetic heart valve thrombosis. J Heart Valve Dis. 1995;4:154-9.
Asante Korang A, Sreeram N, McKay R, Arnold R. Thrombolysis with tissue type plasminogen activator following cardiac surgery in children. Int J Cardiol. 1992;35:317-2.