Prosthetic valve trhombosis
Authors: Alarcon De La Lastra Cubiles IALC , Mialdea Salmeron DMS , Puche Garcia JEPG , Garcia Molinero DGM , Cabeza Lainez PCL , Hernandez Vicente NHV , Gordillo Brenes AGB , Noval Morillas INM , Heras Jimenez LHJ , Benjumea Rodriguez JBR , Gonzalez Guerrero CGG , Leon Montanes LLM , Izaga Torralba EIT , Barranco Perez MBP , Vazquez Garcia RVG 
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Prosthetic valve thrombosis (DVT) is a  very serious complication, with high morbidity and mortality, a high risk of stroke during hospital admission, and which occurs especially in patients with poorly anticoagulated mechanical prostheses.

Therapeutic options available for DVT are surgery, with or without prosthetic replacement, and intravenous thrombolysis. However, there is no randomized study comparing these two interventions. Therefore optional treatment is controversial. This is also reflected in the current clinical practice guidelines of international scientific societies of the year 2017, where the American College of Cardiology / American Heart Association considers surgery and thrombolysis as comparable treatments (Class I), and On the other hand, the European Society of Cardiology (ESC) opts for surgery, leaving thrombolysis only for when surgery is not available, has a very high risk or for cases of right valve thrombosis.

Purpose

In our center we have used a thrombolysis regimen with low doses of t-PA and in slow infusion with adequates results, proposed by Özkan et al. with 25 mg of t-PA administered over 25 hours, repeating this dose up to DVT resolution or a maximum of 8 times.

Methods

We reviewed eleven patients, all with mechanical valve prostheses, six treated with surgery and five with systemic thrombolysis. Of the latter, two cases were treated with a high-dose and accelerated t-PA regimen (10 mg bolus and 90 mg in 2 hours) and the other three cases with low and ultra-slow doses (25 mg in 25 hours). We consider the normalization of the mean transvalvular gradients and the resolution of regurgitation in cases of prosthetic insufficiency a successful result. The mean age was 62.6 years and the mean time from surgery to DVT of 84.9 months. Most of the patients belonged to class III and IV of the NYHA. Anticoagulation was subtherapeutic in 80% of cases. The thrombolysis success rate was 100%.  Of the three cases of ultra-slow pattern, only one of them required a second dose. No side effects or complications were observed. In the surgery group, two patients died during hospital admission as a result of shock and a state of low postoperative cardiac output. In the thrombolysis group, there was only one deceased at 8 months, although not related to DVT related to metastatic melanoma.

Results

We observed a full success rate in the resolution of DVT, with no complications in cases of thrombolysis compared to surgery. Bolus ultra-slow infusion of t-PA is equally effective in resolving DVT, although logically with less bleeding risk due to the dose used and the time of administration, without embolic events having been observed due to slower lysis of the thrombus or new thrombosis during a year of follow-up.

Conclusion

According to our results treatment with low-dose and ultra-slow t-PA regimen will be the initial therapeutic option in clinical practice guidelines given the safety, low cost, and efficacy.

Abstract Figure. valvular thrombosis. Evolution.