900
© 2015 Wiley Periodicals, Inc.
LETTER TO THE EDITOR __________________________________________________________
Current Status of Thrombolytic Therapy in the Management of Prosthetic Valve Thrombosis € € rsoy, M.D.,* Macit KalSc ık, M.D.,y and Mehmet Ozkan, Mustafa Ozan Gu M.D.z,§ _ *Department of Cardiology, Gaziemir State Hospital, Izmir, Turkey; yDepartment of _ Cardiology, Iskilip Atıf Hoca State Hospital, CS orum, Turkey; zDepartment of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey; and §Department of Cardiology, Kars Kafkas University, Faculty of Medicine, Kars, Turkey doi: 10.1111/jocs.12569 (J Card Surg 2015;30:900) Dear Editor, We have recently read with great interest the article reported by Separham et al. which was published in the last issue of the Journal of Cardiac Surgery.1 Thanks to the authors for their contribution of the present report that evaluates the clinical characteristics and outcomes of patients with prosthetic valve thrombosis (PVT) over a 10 year period. On the other hand, we want to make essential criticisms regarding some major drawbacks about the study. PVT is a life-threatening complication of valve surgery. Treatment modalities for PVT include anticoagulation with heparin, thrombolytic therapy (TT),2–4 and surgery.5 Guidelines lack definitive class I recommendations due to lack of randomized controlled trials, and usually leave the choice of treatment to the clinician’s experience. As the authors have stated obstructive PVT carries a high risk of mortality. In the current study, 11.7% of patients died before any type of treatment necessitating urgent therapy. They also found that thrombolytic therapy with streptokinase was associated with higher complication and mortality compared to surgery. The success rates were lower compared to surgical group. Furthermore, TT was complicated by intracranial hemorrhage, ischemic stroke, and even death. However, in the current study, the number of the patients who Data sharing: No additional data Contributorship: All of the authors contributed planning, conduct, and reporting of the work. All contributors are responsible for the overall content as guarantors. Funding: No funding. Competing interests: All of the authors have no conflict of interest. €rsoy, M.D., DepartAddress for correspondence: Mustafa Ozan Gu €rkiye. Fax: þ90 ment of Cardiology, Gaziemir State Hospital, _Izmir, Tu 232 290 93 12; e-mail: [email protected]
underwent TT is limited and the safety of streptokinase regimen is a major concern. Alternative TT regimens have been the focus of research in recent studies. One of these published studies was the TROIA trial,3 which included the largest cohort of PVT patients published to date and compared different TT regimens. Low dose (25 mg) and slow (6 hours) infusion of t-PA without bolus with repetition as needed as a first line therapy was found to be the safest regimen with no loss of effectiveness compared with higher doses or rapid infusions of SKZ or t-PA. Although the TROIA trial does not include a surgical arm, it still favors TT over surgery in terms of mortality rate which has been reported as 18% in a recent meta-analysis.5 Nevertheless, without a head-to-head randomized trial between lytics and surgery, the superiority of one over the other will remain speculative. REFERENCES 1. Separham A, Ghaffari S, Aslanabadi N, et al: Prosthetic valve thrombosis. J Card Surg 2015; Jan 12.doi: 10.1111/ jocs.12510 [Epub ahead of print]. € 2. Ozkan M, Kaymaz C, Kırma C, et al: Intravenous thrombolytic treatment of mechanical prosthetic valve thrombosis: A study using serial transesophageal echocardiography. J Am Coll Cardiol 2000;35:1881–1889. € 3. Ozkan M, Gunduz S, Biteker M, et al: Comparison of different TEE-guided thrombolytic regimens for prosthetic valve thrombosis: The TROIA Trial. JACC Cardiovasc Imaging 2013;6:206–216. € 4. Ozkan M, Cakal B, Karakoyun S, et al: Thrombolytic therapy for the treatment of prosthetic heart valve thrombosis in pregnancy with low-dose, slow infusion of tissue-type plasminogen activator. Circulation 2013;128:532–540. 5. Castilho FM, De Sousa MR, MendonSc a AL, et al: Thrombolytic therapy or surgery for valve prosthesis thrombosis: Systematic review and meta-analysis. J Thromb Haemost 2014;12(8):1218–1228.
© 2015 Wiley Periodicals, Inc.
LETTER TO THE EDITOR __________________________________________________________
Current Status of Thrombolytic Therapy in the Management of Prosthetic Valve Thrombosis € € rsoy, M.D.,* Macit KalSc ık, M.D.,y and Mehmet Ozkan, Mustafa Ozan Gu M.D.z,§ _ *Department of Cardiology, Gaziemir State Hospital, Izmir, Turkey; yDepartment of _ Cardiology, Iskilip Atıf Hoca State Hospital, CS orum, Turkey; zDepartment of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey; and §Department of Cardiology, Kars Kafkas University, Faculty of Medicine, Kars, Turkey doi: 10.1111/jocs.12569 (J Card Surg 2015;30:900) Dear Editor, We have recently read with great interest the article reported by Separham et al. which was published in the last issue of the Journal of Cardiac Surgery.1 Thanks to the authors for their contribution of the present report that evaluates the clinical characteristics and outcomes of patients with prosthetic valve thrombosis (PVT) over a 10 year period. On the other hand, we want to make essential criticisms regarding some major drawbacks about the study. PVT is a life-threatening complication of valve surgery. Treatment modalities for PVT include anticoagulation with heparin, thrombolytic therapy (TT),2–4 and surgery.5 Guidelines lack definitive class I recommendations due to lack of randomized controlled trials, and usually leave the choice of treatment to the clinician’s experience. As the authors have stated obstructive PVT carries a high risk of mortality. In the current study, 11.7% of patients died before any type of treatment necessitating urgent therapy. They also found that thrombolytic therapy with streptokinase was associated with higher complication and mortality compared to surgery. The success rates were lower compared to surgical group. Furthermore, TT was complicated by intracranial hemorrhage, ischemic stroke, and even death. However, in the current study, the number of the patients who Data sharing: No additional data Contributorship: All of the authors contributed planning, conduct, and reporting of the work. All contributors are responsible for the overall content as guarantors. Funding: No funding. Competing interests: All of the authors have no conflict of interest. €rsoy, M.D., DepartAddress for correspondence: Mustafa Ozan Gu €rkiye. Fax: þ90 ment of Cardiology, Gaziemir State Hospital, _Izmir, Tu 232 290 93 12; e-mail: [email protected]
underwent TT is limited and the safety of streptokinase regimen is a major concern. Alternative TT regimens have been the focus of research in recent studies. One of these published studies was the TROIA trial,3 which included the largest cohort of PVT patients published to date and compared different TT regimens. Low dose (25 mg) and slow (6 hours) infusion of t-PA without bolus with repetition as needed as a first line therapy was found to be the safest regimen with no loss of effectiveness compared with higher doses or rapid infusions of SKZ or t-PA. Although the TROIA trial does not include a surgical arm, it still favors TT over surgery in terms of mortality rate which has been reported as 18% in a recent meta-analysis.5 Nevertheless, without a head-to-head randomized trial between lytics and surgery, the superiority of one over the other will remain speculative. REFERENCES 1. Separham A, Ghaffari S, Aslanabadi N, et al: Prosthetic valve thrombosis. J Card Surg 2015; Jan 12.doi: 10.1111/ jocs.12510 [Epub ahead of print]. € 2. Ozkan M, Kaymaz C, Kırma C, et al: Intravenous thrombolytic treatment of mechanical prosthetic valve thrombosis: A study using serial transesophageal echocardiography. J Am Coll Cardiol 2000;35:1881–1889. € 3. Ozkan M, Gunduz S, Biteker M, et al: Comparison of different TEE-guided thrombolytic regimens for prosthetic valve thrombosis: The TROIA Trial. JACC Cardiovasc Imaging 2013;6:206–216. € 4. Ozkan M, Cakal B, Karakoyun S, et al: Thrombolytic therapy for the treatment of prosthetic heart valve thrombosis in pregnancy with low-dose, slow infusion of tissue-type plasminogen activator. Circulation 2013;128:532–540. 5. Castilho FM, De Sousa MR, MendonSc a AL, et al: Thrombolytic therapy or surgery for valve prosthesis thrombosis: Systematic review and meta-analysis. J Thromb Haemost 2014;12(8):1218–1228.
