Thrombolysis Bests Surgery In Most Cases Of Obstructive Mechanical Valve Thrombosis
Thrombotic obstruction is an uncommon but important late complication of prosthetic heart valves, and with older prosthesis models with a single tilting disc, thrombosis of left-sided valves often led to rapid hemodynamic deterioration and acute presentation with pulmonary edema. A recent study suggests that administration of low dose and slow infusion of tissue plasminogen activator (tPA) is effective and potential alternative therapy for patients with obstructive prosthetic valve thrombosis (PVT). The study findings were published in the Journal of the American College of Cardiology on March 07, 2022.
Prosthetic valve thrombosis (PVT) is one of the life-threatening complications of prosthetic heart valve replacement. However, the optimal treatment of PVT remains controversial between thrombolytic therapy (TT) and surgery remain unclear. Therefore, Dr Mehmet Özkan and his team conducted a study to prospectively evaluate the outcomes of TT and surgery as the first-line treatment strategy in patients with obstructive PVT.
HATTUSHA is a multicenter observational prospective study in which the researchers included 158 obstructive PVT patients who were treated at one of eight tertiary centers between December 2013 and December 2020. They performed TT using slow (6 hours) and/or ultraslow (25 hours) infusion of low-dose tissue plasminogen activator (t-PA) (25 mg) mostly in repeated sessions. The primary endpoint of the study was 3-month mortality following TT or surgery.
Key findings of the study:
- Among 158 patients, 83 (52.5%) patients had TT and 75 (47.5%) patients undergone surgery.
- Upon analysis, the researchers observed that the success rate of TT was 90.4% with a median t-PA dose of 59 mg.
- They found that the hospital length of stay was longer and rates of minor and major complications, major bleeding, re-thrombosis, and mortality at 3 months (the primary endpoint) were all higher with surgery.
The authors concluded, "Low-dose and slow/ultraslow infusion of t-PA were associated with low complications and mortality and high success rates and should be considered as a viable treatment in patients with obstructive PVT."
In an accompanying editorial, Dr Hartzell V. Schaff wrote, "it is unlikely that such studies will guide medical versus surgical therapy of valve thrombosis in the near future," But ultimately these data "establish the effectiveness and relative safety of slow and/or ultraslow tPA infusion, which should be offered to most eligible patients with thrombotic obstruction of mechanical valves," he concludes.
For further information:
DOI: https://www.jacc.org/doi/abs/10.1016/j.jacc.2021.12.027
Keywords:
Obstructive prosthetic valve thrombosis, HATTUSHA Study, mechanical valves, tPA, thrombolytic therapy, tissue plasminogen activator, Low dose of tPA, Slow infusion of tPA, thrombosis, Journal of the American College of Cardiology.
