LETTERS TO THE EDITOR
Thrombolysis should be regarded as first-line therapy for prosthetic valve thrombosis in the absence of contraindications
Maria Lengyel, MD, FACC, FESC*
* Hungarian Institute of Cardiology, Haller 29, Budapest, 1096, Hungary
(Email: vargakat{at}kardio.hu).
I read with great interest the retrospective, multicentric Prostethic Valve Thrombolysis-Role of Transesophageal Echocardiography (PRO-TEE) study in a recent issue of the Journal (1). The results of the registry appear to confirm our previous and rather conservative recommendations (2). According to these guidelines obstructive thrombi in patients presenting in NYHA functional class III to IV should be treated with thrombolysis if the surgical risk is high. However, the basis of these recommendations was an international consensus conference held in 1994, when thrombolysis of left-sided prosthetic valves was a rather debated approach. A review of 53 studies cited in the published reports indicates the results of thrombolysis being inferior in the period between 1974 and 1995 than between 1996 and 2003: success rate 77% versus 90%, embolism rate 13% versus 4%, death rate 7.5% versus 2.5%, while the number of treated episodes was virtually the same (235 vs. 234). Recent reports and reviews recommend thrombolysis as the first-line approach in the management of prosthetic valve thrombosis irrespective of functional class or thrombus size (3–5).
In contrast, contributors to the registry conclude that thrombolysis should be limited to patients with thrombus size  0.8 cm2 as measured by transesophageal echocardiography (TEE). This conclusion was based on a small number of patients coming from 14 centers over 16 years. The selection of patients into the registry may have been biased (1). Moreover, in obstructive cases the fixed thrombus usually cannot be measured within the valve orifice (3,4).
In contrast, mobile nonobstructive thrombi are easily measurable and in most cases large, at least in length, but thrombolysis of these thrombi can be performed with negligible embolic risk (3–5). The role of TEE is particularly essential to reveal thrombus in nonobstructive cases (3) and serial TEE is required to monitor the efficacy of thrombolysis (4,6). Assessment of "hemodynamic" and "clinical results" without "thrombolytic results" does not allow the evaluation of treatment results in nonobstructive cases. In summary, despite our previous recommendations I consider use of thrombolysis in all patients with prosthetic valve thrombosis irrespective of functional class and thrombus size unless contraindications exist. Thus, TEE must be performed before and during treatment.
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References
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1. Tong TA, Roudaut R, Özkan M, et al. the 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.[Abstract/Free Full Text]
2. Lengyel M, Fuster V, Keltai M, et al. Guidelines for the management of left-sided prosthetic valve thrombosis: a role for thrombolytic therapy J Am Coll Cardiol 1997;30:1521-1526.[Abstract]
3. Lengyel M, Vándor 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.[Web of Science][Medline]
4. Ozkan M, Kaymaz C, Kirma 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.[Abstract/Free Full Text]
5. Rinaldi CA, Heppell RM, Chambers JB. Treatment of left-sided prosthetic valve thrombosis: thrombolysis or surgery? J Heart Valve Dis 2002;11:839-843.[Medline]
6. Alpert JS. The thrombosed prosthetic valve J Am Coll Cardiol 2003;41:659-660.[Free Full Text]
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