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Intravenous thrombolytic treatment of mechanical prosthetic valve thrombosis: a study using serial transesophageal
Insights
Transesophageal echocardiography-guided intravenous thrombolysis for prosthetic valve thrombosis is effective. Serial slow infusions, guided by echocardiography, achieve high success rates with low complication risks.
Area of Science:
- Cardiology
- Interventional Cardiology
- Echocardiography
Background:
- Prosthetic valve thrombosis is a rare but serious complication.
- Intravenous thrombolysis is a proposed alternative to surgery.
Purpose of the Study:
- To analyze the efficacy and safety of intravenous thrombolytic treatment guided by transesophageal echocardiography (TEE) for prosthetic valve thrombosis.
Main Methods:
- 32 symptomatic patients with prosthetic valve thrombosis underwent 54 thrombolytic sessions over four years.
- Transesophageal echocardiography (TEE) was used for baseline and follow-up assessments (98 total examinations).
- Streptokinase was the initial agent, with tissue plasminogen activator or urokinase used for recurrent thrombosis.
Main Results:
- Initial treatment success was 53%, increasing to 88% after repeated sessions guided by TEE.
- Thrombus characteristics on TEE correlated with treatment response; obstructive thrombi had lower success rates (40%) than nonobstructive ones (75%).
- Slow infusion (15-24h) demonstrated similar success to rapid infusion (3h) but with fewer major complications.
Conclusions:
- Intravenous slow infusion thrombolysis guided by serial TEE is a safe and effective treatment for prosthetic valve thrombosis.
- This approach offers a high success rate with a low risk of complications.
- Echocardiographic guidance is crucial for optimizing treatment outcomes.
Objective:
We analyzed the results of intravenous thrombolytic treatment under transesophageal echocardiographic (TEE) guidance in prosthetic valve thrombosis.
Background:
Thrombotic occlusion of prosthetic valves continues to be an uncommon but serious complication. Intravenous thrombolytic treatment has been proposed as an alternative to surgical intervention.
Methods:
In a four-year period, 32 symptomatic patients with prosthetic valve related thrombosis underwent 54 thrombolytic treatment sessions for the treatment of 36 distinct episodes. All patients had low international normalized ratio values at the presentation. Transesophageal echocardiography was performed at baseline and repeated after each thrombolytic treatment session (total 98 TEE examinations). Streptokinase was used as the initial agent with a repeat dose given within 24 h when necessary. Recurrent thrombosis was treated either with tissue plasminogen activator or urokinase.
Results:
The initial success after first dose was only 53% (17/32) but increased up to 88% (28/32) after repeated thrombolytic sessions upon documentation of suboptimal results on TEE examination (p < 0.01). In addition, four asymptomatic patients with large thrombi were also successfully treated with single infusion. The TEE characteristics of thrombus correlated with clinical presentation and response to lytics. Success was achieved with single lytic infusion in 40% of the obstructive thrombi as compared with 75% of the nonobstructive ones (p < 0.05). The success rates of lytic treatment were similar for mitral versus aortic valves, and for tilting disk versus bileaflet valves. Rapid (3 h) and slow (15 to 24 h) infusion of streptokinase resulted in similar success rates. However, major complications (three patients) occurred only in the rapid infusion group.
Conclusion:
In patients with prosthetic valve thrombosis, intravenous slow infusion thrombolysis given in discrete, successive sessions guided by serial TEE and transthoracic echocardiography can be achieved with a low risk of complications and a high rate of success.