Intravenous thrombolytic treatment of mechanical prosthetic valve thrombosis: A study using serial transesophageal echocardiography

OBJECTIVE We analyzed the results of intravenous thrombolytic treatment und er transesophageal echocardiographic (TEE) guidance in prosthetic valve thr ombosis. BACKGROUND Thrombotic occlusion of prosthetic valves continues to be an unc ommon but serious complication. Intravenous thrombolytic treatment has been proposed as an alternative to surgical intervention. METHODS In a four-year period, 32 symptomatic patients with prosthetic valv e related thrombosis underwent 54 thrombolytic treatment sessions for the t reatment of 36 distinct episodes. All patients had low international normal ized ratio values at the presentation. Transesophageal echocardiography was performed at baseline and repeated after each thrombolytic treatment sessi on (total 98 TEE examinations). Streptokinase was used as the initial agent with a repeat dose given within 24 h when necessary. Recurrent thrombosis was treated either with tissue plasminogen activator or urokinase. RESULTS The initial success after first dose was only 53% (17/32) but incre ased up to 88% (28/32) after repeated thrombolytic sessions upon documentat ion of suboptimal results on TEE examination (p < 0.01). In addition, four asymptomatic patients with large thrombi were also successfully treated wit h single infusion. The TEE characteristics of thrombus correlated with clin ical presentation and response to lytics. Success was achieved with single lytic infusion in 40% of the obstructive thrombi as compared with 75% of th e nonobstructive ones (p < 0.05). The success rates of lytic treatment were similar for mitral versus aortic valves, and for tilting disk versus bilea flet valves. Rapid (3 h) and slow (15 to 24 h) infusion of streptokinase re sulted in similar success rates. However, major complications (three patien ts) occurred only in the rapid infusion group. CONCLUSION In patients with prosthetic valve thrombosis, intravenous slow i nfusion thrombolysis given in discrete, successive sessions guided by seria l TEE and transthoracic echocardiography can be achieved with a low risk of complications and a high rate of success. (J Am Coll Cardiol 2000;35:1881- 9) (C) 2000 by the American College of Cardiology.