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J Thorac Cardiovasc Surg 2008;136:1104-1105
© 2008 The American Association for Thoracic Surgery
Letter to the Editor |
Institute of Cardiology and Cardiovascular Surgery, Havana, Cuba
To the Editor:
Despite the progress in anesthesia, cardiac surgery, and perioperative care, the therapeutic decision in prosthetic valve thrombosis (PVT) remains in discussion.
In recent years thrombolytic therapy has won acceptance, and for many it is the first therapeutic choice because the mortality is lower than that of surgical treatment and its application is easy and rapid.1,2
We do not know with certainty how long it takes thrombolytic therapy to deocclude a thrombosed prosthesis, although it probably takes less time than surgery because of all the equipment needed to implement aggressive treatment.
The great risk of a redo valve replacement in these generally critically ill patients is also widely appreciated. The main risks of thrombolytic treatment are the thromboembolic complications, which appear in from 4% to 13% of the patients, and bleeding, which occurs in from 1.4% to 5%.3
We have read with interest the excellent report written by Nguyen and collegues.4 They have added an important case to the medical literature for the successful application of the thrombolytic protocol with recombinant tissue-type plasminogen activator (rt-PA), which has not been used previously in the management of PVT. It consisted in a continuous intravenous infusion of rt-PA at a rate of 1 mg/h together with the administration of heparin in a continuous intravenous infusion of 3 U · kg–1 · h–1. The duration of treatment was 80 hours. At the end of the fibrinolytic infusion, the transprosthetic gradients had decreased from a peak and mean of 158 and 86 mm Hg to 48 and 25 mm Hg, respectively. Fluoroscopy confirmed normal motion of the prosthetic valve. The patient's symptoms resolved.
We would like to make some comments related to this therapeutic regimen. Treatment with rt-PA in PVT has not been widely used. It has been blamed for a major risk of embolism other than thrombolysis for its potential and velocity of the infusion. Shapira and collegues5 proved the efficacy and safety of rt-PA, with the additional advantage that if the thrombolytic treatment fails, surgery can be used with less risk for its less lytic systemic effect.
The regimen of administration is not well defined. This protocol probably needs a longer course and lower dose to provide better thrombolytic efficacy with less risk of complications in hemodynamically stable patients, because they do not need a prompt thrombolytic effect. An accelerated protocol with rt-PA should be reserved for critically ill patients.
Until now, streptokinase is the most effective thrombolytic agent used, alone or as a part of a sequential fibrinolytic treatment in the PVT.
Despite the favorable evidence of thrombolytic therapy in the treatment of the PVT, more data should be gathered to obtain a general consensus of the ideal management of this complication.
References
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