898
© 2015 Wiley Periodicals, Inc.
LETTER TO THE EDITOR __________________________________________________________
Management Dilemma in Acute Prosthetic Valve Thrombosis: Surgery or Thrombolysis? Murat Biteker, M.D.,* Ozcan Basaran, M.D.,* Volkan Dogan, M.D.,* and Ismail Bolat, M.D.y la Sıtkı KoSc man University, Mug la, *Faculty of Medicine, Department of Cardiology, Mug la, Turkey Turkey; and yDepartment of Cardiology, Fethiye State Hospital, Mug doi: 10.1111/jocs.12566 (J Card Surg 2015;30:898)
Dear Editor, We have recently read with great interest the article by Separham et al.1 reporting a retrospective analysis of 85 episodes of prosthetic valve thrombosis (PVT) in 80 patients treated over a 10-year period. Although the authors found thrombolytic therapy (TT) was less effective and had more complications, we want to address some points that merit more attention. Our first concern is about the number of patients. In the study group, 16 patients received TT, 56 patients underwent surgery, and 10 patients were treated with intensification of anticoagulation. The total number of the patients is 82 not 80. Our second concern is about lack of comparison of baseline characteristics in patients undergoing surgery and thrombolysis. If the patients treated with TT were sicker or had more comorbidities, the negative results of thrombolysis would be inevitable. PVT is a life-threatening complication whose management remains controversial. Although review of literature for management of PVT reveals no set guidelines, TT, intensification of anticoagulation or surgery are the currently available options.2,3 Recent data have shown that thrombolysis is superior to surgery, even in the most critical patients with PVT.3 Although there is a lack of randomized controlled prospective trials comparing surgery and TT in PVT, it was shown that intravenous slow infusion thrombolysis given in discrete, successive sessions guided by serial transesophageal echocardiography could be achieved with a low risk of complications and a high rate of success even in patients within New York Heart
Address for correspondence: Ozcan Basaran, M.D., Faculty of la Sıtkı Kocman UniverMedicine, Department of Cardiology, Mug la, Turkey. sity, Orhaniye Mahallesi Ismet Catak Caddesi, Mug Fax: þ90 252 213 07 62; e-mail: [email protected]
Association class III or IV.3,4 Keuleers et al.5 also showed that thrombolysis was an attractive first-line therapy for patients with PVT, with clinical outcomes comparing favorably with the standard surgical approach. Our last concern is about left atrial thrombus which is accepted as a contraindication for thrombolysis and should be ruled out by transesophageal echocardiography before TT. In the current study, the authors might have performed thrombolysis without prior exclusion of left atrial thrombus. In conclusion, we think that low-dose, slow infusion of TT under the guidance of serial transesophageal echocardiography should be the first-line therapy for PVT patients unless contraindicated and this article has a significant negative teaching value.
REFERENCES 1. Separham A, Ghaffari S, Aslanabadi N, et al: Prosthetic valve thrombosis. J Card Surg 2015;30(3):246–250. €ndu €z S, et al: Thrombolysis of an 2. Biteker M, Duran NE, Gu acute prosthetic mitral valve thrombosis presented with cardiogenic shock under the guidance of continuous transoesophageal monitoring. Eur J Echocardiogr 2009; 10(3):468–470. € €ndu €z S, Biteker M, et al: Comparison of 3. Ozkan M, Gu different TEE-guided thrombolytic regimens for prosthetic valve thrombosis: The TROIA trial. JACC Cardiovasc Imaging 2013;6(2):206–216. 4. Biteker M, Ozkan M. Treatment of obstructive prosthetic heart valve thrombosis in pregnancy. J Card Surg 2010; 25(2):206. 5. Keuleers S, Herijgers P, Herregods MC, et al: Comparison of thrombolysis versus surgery as a first line therapy for prosthetic heart valve thrombosis. Am J Cardiol 2011; 107(2):275–279.
© 2015 Wiley Periodicals, Inc.
LETTER TO THE EDITOR __________________________________________________________
Management Dilemma in Acute Prosthetic Valve Thrombosis: Surgery or Thrombolysis? Murat Biteker, M.D.,* Ozcan Basaran, M.D.,* Volkan Dogan, M.D.,* and Ismail Bolat, M.D.y la Sıtkı KoSc man University, Mug la, *Faculty of Medicine, Department of Cardiology, Mug la, Turkey Turkey; and yDepartment of Cardiology, Fethiye State Hospital, Mug doi: 10.1111/jocs.12566 (J Card Surg 2015;30:898)
Dear Editor, We have recently read with great interest the article by Separham et al.1 reporting a retrospective analysis of 85 episodes of prosthetic valve thrombosis (PVT) in 80 patients treated over a 10-year period. Although the authors found thrombolytic therapy (TT) was less effective and had more complications, we want to address some points that merit more attention. Our first concern is about the number of patients. In the study group, 16 patients received TT, 56 patients underwent surgery, and 10 patients were treated with intensification of anticoagulation. The total number of the patients is 82 not 80. Our second concern is about lack of comparison of baseline characteristics in patients undergoing surgery and thrombolysis. If the patients treated with TT were sicker or had more comorbidities, the negative results of thrombolysis would be inevitable. PVT is a life-threatening complication whose management remains controversial. Although review of literature for management of PVT reveals no set guidelines, TT, intensification of anticoagulation or surgery are the currently available options.2,3 Recent data have shown that thrombolysis is superior to surgery, even in the most critical patients with PVT.3 Although there is a lack of randomized controlled prospective trials comparing surgery and TT in PVT, it was shown that intravenous slow infusion thrombolysis given in discrete, successive sessions guided by serial transesophageal echocardiography could be achieved with a low risk of complications and a high rate of success even in patients within New York Heart
Address for correspondence: Ozcan Basaran, M.D., Faculty of la Sıtkı Kocman UniverMedicine, Department of Cardiology, Mug la, Turkey. sity, Orhaniye Mahallesi Ismet Catak Caddesi, Mug Fax: þ90 252 213 07 62; e-mail: [email protected]
Association class III or IV.3,4 Keuleers et al.5 also showed that thrombolysis was an attractive first-line therapy for patients with PVT, with clinical outcomes comparing favorably with the standard surgical approach. Our last concern is about left atrial thrombus which is accepted as a contraindication for thrombolysis and should be ruled out by transesophageal echocardiography before TT. In the current study, the authors might have performed thrombolysis without prior exclusion of left atrial thrombus. In conclusion, we think that low-dose, slow infusion of TT under the guidance of serial transesophageal echocardiography should be the first-line therapy for PVT patients unless contraindicated and this article has a significant negative teaching value.
REFERENCES 1. Separham A, Ghaffari S, Aslanabadi N, et al: Prosthetic valve thrombosis. J Card Surg 2015;30(3):246–250. €ndu €z S, et al: Thrombolysis of an 2. Biteker M, Duran NE, Gu acute prosthetic mitral valve thrombosis presented with cardiogenic shock under the guidance of continuous transoesophageal monitoring. Eur J Echocardiogr 2009; 10(3):468–470. € €ndu €z S, Biteker M, et al: Comparison of 3. Ozkan M, Gu different TEE-guided thrombolytic regimens for prosthetic valve thrombosis: The TROIA trial. JACC Cardiovasc Imaging 2013;6(2):206–216. 4. Biteker M, Ozkan M. Treatment of obstructive prosthetic heart valve thrombosis in pregnancy. J Card Surg 2010; 25(2):206. 5. Keuleers S, Herijgers P, Herregods MC, et al: Comparison of thrombolysis versus surgery as a first line therapy for prosthetic heart valve thrombosis. Am J Cardiol 2011; 107(2):275–279.
