Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL,. Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACCy. AHA 2006 ...
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class, thrombus size and previous history of stroke should be taken into account when making this decision. Small thrombus size (-0.8 cm2), particularly in the absence of previous stroke disease, may favour thrombolysis in view of the high success rates and low complication rates demonstrated in this situation. Additionally, treatment with a thrombolytic does not preclude subsequently reverting to surgical management in the event of failure. Presentation in a high NYHA class of heart failure or cardiogenic shock is the most difficult patient to decide between surgery and thrombolysis. Surgery for these patients may remain the mainstay of treatment unless the clot burden is particularly small or the patient’s co-morbidities make surgery unacceptably high-risk.
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References w16x w1x Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405–409. w2x American College of CardiologyyAmerican Heart Association Task Force on Practice Guidelines, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, Bonow RO, Carabello BA, Kanu C, de Leon AC Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACCy AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of CardiologyyAmerican Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 2006;114:e84–231. w3x Lengyel M, Horstkotte D, Voller H, Mistiaen WP, Working Group Infection, Thrombosis, Embolism and Bleeding of the Society for Heart Valve Disease. Recommendations for the management of prosthetic valve thrombosis. J Heart Valve Dis 2005;14:567–575. w4x Caceres-Loriga FM, Perez-Lopez H, Santos-Gracia J, Morlans-Hernandez K. Prosthetic heart valve thrombosis: pathogenesis, diagnosis and management. Int J Cardiol 2006;110:1–6. w5x Lengyel M. Thrombolysis should be regarded as first-line therapy for prosthetic valve thrombosis in the absence of contraindications. J Am Coll Cardiol 2005;45:325. w6x Tong AT, Roudaut R, Ozkan M, Sagie A, Shahid MS, Pontes Junior SC, Carreras F, Girard SE, Arnaout S, Stainback RF, Thadhani R, Zoghbi WA, Prosthetic Valve Thrombolysis – Role of Transesophageal Echocardiography (PRO-TEE) Registry Investigators. 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. w7x Caceres-Loriga FM, Perez-Lopez H, Morlans-Hernandez K, FacundoSanchez 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. w8x Roudaut R, Lafitte S, Roudaut MF, Courtault C, Perron JM, Jais C, Pillois X, Coste P, DeMaria A. Fibrinolysis of mechanical prosthetic valve thrombosis: a single-center study of 127 cases. J Am Coll Cardiol 2003;41:653–658. w9x Kumar S, Garg N, Tewari S, Kapoor A, Goel PK, Sinha N. Role of thrombolytic therapy for stuck prosthetic valves: a serial echocardiographic study. Indian Heart J 2001;53:451–457. w10x Lengyel M, Vandor L. The role of thrombolysis in the management of left-sided prosthetic valve thrombosis: a study of 85 cases diagnosed
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by transesophageal echocardiography. J Heart Valve Dis 2001;10:636– 649. Gupta D, Kothari SS, Bahl VK, Goswami KC, Talwar KK, Manchanda SC, Venugopal P. Thrombolytic therapy for prosthetic valve thrombosis: short- and long-term results. Am Heart J 2000;140:906–916. 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. Agrawal D, Dubey S, Saket B, Bhargava M, Mehta N, Lohchab SS, Satsangi DK, Nigam M, Gupta BK, Khanna SK. Thrombolytic therapy for prosthetic valve thrombosis in Third World countries. Indian Heart J 1997;49:383–386. Reddy NK, Padmanabhan TN, Singh S, Kumar DN, Raju PR, Satyanarayana PV, Rao DP, Rajagopal P, Raju BS. Thrombolysis in left-sided prosthetic valve occlusion: immediate and follow-up results. Ann Thorac Surg 1994;58:462–470. Roudaut R, Roques X, Lafitte S, Choukroun E, Laborde N, Madona F, Deville C, Baudet E. Surgery for prosthetic valve obstruction. A single center study of 136 patients. Eur J Cardiothorac Surg 2003;24:868–872. Deviri E, Sareli P, Wisenbaugh T, Cronje SL. Obstruction of mechanical heart valve prostheses: clinical aspects and surgical management. J Am Coll Cardiol 1991;17:646–650.
eComment: Thrombolytic therapy or surgery as management of prosthetic valve thrombosis? Author: Senol Yavuz, Bursa Yu ¨ksek Ihtisas Education and Research Hospital, Bursa 16330, Turkey doi:10.1510/icvts.2007.165399A First of all, I would like to congratulate Das et al. w1x 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 w2– 5x. 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 w5x. 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 w1x 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. w2x 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. w3x Caceres-Loriga FM, Perez-Lopez H, Morlans-Hernandez K, FacundoSanchez H, Santos-Gracia J, Valiente-Mustelier J, Rodiles-Aldana F,
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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. w4x 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. w5x 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.
