Correspondence

Recombinant Tissue Plasminogen Activator for Prosthetic Mitral-Valve Thrombosis

N Engl J Med 1995; 333:259July 27, 1995

Article

To the Editor:

The reported incidence of thrombosis of prosthetic mitral or aortic valves ranges from 0.03 to 4.3 percent per year.1 Thrombectomy or valve replacement is the conventional treatment for this condition, with an associated mortality rate ranging from 4.7 to 20 percent.2 Thrombolysis is emerging as a promising alternative to surgery, particularly in critically ill patients, with a success rate ranging from 75 to 83 percent.1 Most patients in published series have been treated with infusions of streptokinase or urokinase for 12 to 24 hours.1,3,4 Not all obstructed valves respond to thrombolysis, however. The valve obstruction is due to the growth of pannus in 20 to 30 percent of cases, and the prolonged infusion of thrombolytic agents may delay emergency surgery in patients with this life-threatening condition. Therefore, a short-acting thrombolytic agent would be desirable to reduce the risk associated with the use of thrombolysis as first-line therapy in patients with prosthetic-valve thrombosis.

Since recombinant tissue plasminogen activator (t-PA) has been found to produce thrombolysis faster than other thrombolytic agents in patients with myocardial infarction5 and has been used safely in a few patients with prosthetic-valve thrombosis, we used it as first-line therapy for mitral-valve thrombosis.

From March 1993 to June 1994, five consecutive patients with prosthetic mitral-valve thrombosis, as documented by transthoracic Doppler ultrasonography (four patients) or visualization of the thrombus by transesophageal echocardiography (one patient), and no contraindications to thrombolysis were treated with intravenous recombinant t-PA (100 mg over a two-hour period) (Table 1Table 1Clinical Characteristics and Outcome of Thrombolysis in Five Patients with Thrombosis of a Prosthetic Mitral Valve.). Intravenous heparin was given after thrombolysis and then replaced by treatment with warfarin plus dipyridamole. Thrombolysis was successful in all five patients (Table 1): symptoms improved markedly, and prosthetic-valve clicks reappeared after a mean (±SD) period of 120±73 minutes (within 2 hours in four patients). No episodes of systemic embolism, clinically important bleeding, or recurrent valve thrombosis were observed. None of the patients required subsequent surgery, and all were alive and well after 13.4±7.9 months of follow-up.

Treatment of patients with thrombosis of a prosthetic valve remains controversial. Our results in five consecutive patients suggest that recombinant t-PA can be used safely in patients with prosthetic-valve thrombosis, resulting in rapid restoration of valve function.

Davide Astengo, M.D.
Ospedale Celesia, 16159 Genoa, Italy

Luigi Badano, M.D.
Ospedale di Nervi, 16167 Genoa, Italy

Daniele Bertoli, M.D.
Ospedale S. Bartolomeo, 19038 Sarzana, Italy

5 References

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   The GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993;329:673-682
   Full Text | Web of Science | Medline

Citing Articles (3)

Citing Articles

1. 1

   Y. Shapira, M. Vaturi, D. Hasdai, A. Battler, A. Sagie. (2003) The safety and efficacy of repeated courses of tissue-type plasminogen activator in patients with stuck mitral valves who did not fully respond to the initial thrombolytic course. Journal of Thrombosis and Haemostasis 1:4, 725-728
   CrossRef

2. 2

   Luigi P Badano, Stefano Domenicucci. (1999) Use of a Common Computerized Program for Echocardiogram Archiving and Reporting Over a Regional Territory: Feasibility and Clinical and Research Impact During a 5-Year Experience. Journal of the American Society of Echocardiography 12:8, 669-678
   CrossRef

3. 3

   Luigi Badano, Roberto Mocchegiani, Daniele Bertoli, Giuseppe DeGaetano, Lorenzo Carratino, Laura Pasetti, Michelangelo Caudullo, Antonietta Budini, Bruno Mannello, Giancarlo Passerone. (1997) Normal echocardiographic characteristics of the sorin bicarbon bileaflet prosthetic heart valve in the mitral and aortic positions. Journal of the American Society of Echocardiography 10:6, 632-643
   CrossRef