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Thrombolytic therapy or surgery as management of prosthetic valve thrombosis?

Bursa Yüksek Ihtisas Education and Research Hospital, Bursa 16330, Turkey

Is thrombolysis or surgery the best option for acute prosthetic valve thrombosis?

First of all, I would like to congratulate Das et al. [1] for the effort in developing this very important and complicated subject. Thrombolytic therapy or surgery as management of prosthetic valve thrombosis currently remains a controversial topic. It has always been a challenge to decide between thrombolytic therapy and surgery when managing patients with prosthetic valve thrombosis in cardiogenic shock. In patients with a thrombosed prosthetic valve, how to perform a safe treatment is the final goal for every cardiologist or cardiac surgeon. The reports from a lot of studies show that intravenous thrombolytic therapy can restore adequate function of the prosthesis thrombosed with low mortality and complication rates [2–5].

We reported a prospective study in which we applied thrombolytic therapy with streptokinase as the first-line treatment in 21 out of 29 patients with a prosthetic mitral valve thrombosis [5]. In our study, patients who refused surgery or who were in NYHA classes III–IV and had unpedunculated thrombus were selected for thrombolytic therapy. Three patients with pedunculated thrombus and five in NYHA functional classes I–II were managed with surgery rather than thrombolytic therapy. We used a guidance of transesophageal echocardiography to monitor the efficacy of the treatment. Two patients were referred for surgery because of failed thrombolysis on the third day and recurrent prosthetic mitral valve thrombosis at six months' follow-up, respectively.

I agree with the conclusion of the authors that surgical approach for these patients may remain the mainstay of treatment unless the clot burden is particularly small or the patient's co-morbidities make surgery an unacceptably high-risk as first-line therapy. As a cardiovascular surgeon, I obviously think that surgical therapy still has an important role in such complicated situations. Therefore, surgical management should be considered to remove persistant thrombus even if prosthetic valve function has been restored to normal or near-normal by thrombolytic therapy.

	References

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1. Das M, Twomey D, Al Khaddour A, Dunning J. Is thrombolysis or surgery the best option for acute prosthetic valve thrombosis? Interact CardioVasc Thorac Surg 2007; 6:806–812.[Abstract/Free Full Text]
2. Lengyel M, Vandor L. The role of thrombolysis in the management of left-sided prosthetic valve thrombosis: a study of 85 cases diagnosed by transesophageal echocardiography. J Heart Valve Dis 2001; 10:636–649.[Medline]
3. Caceres-Loriga FM, Perez-Lopez H, Morlans-Hernandez K, Facundo-Sanchez H, Santos-Gracia J, Valiente-Mustelier J, Rodiles-Aldana F, Marrero-Mirayaga MA, Betancourt BY, Lopez-Saura P. Thrombolysis as first choice therapy in prosthetic heart valve thrombosis. A study of 68 patients. J Thromb Thrombolysis 2006; 21:185–190.[CrossRef][Medline]
4. Ozkan M, Kaymaz C, Kirma C, Sonmez K, Ozdemir N, Balkanay M, Yakut C, Deligonul U. Intravenous thrombolytic treatment of mechanical prosthetic valve thrombosis: a study using serial transesophageal echocardiography. J Am Coll Cardiol 2000; 35:1881–1889.[Abstract/Free Full Text]
5. Koca V, Bozat T, Sarikamis C, Akkaya V, Yavuz S, Ozdemir A. The use of transesophageal echocardiography guidance of thrombolytic therapy in prosthetic mitral valve thrombosis. J Heart Valve Dis 2000; 9:374–378.[Medline]

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