Thrombolytic therapy for prosthetic valve thrombosis: Short- and long-termresults

Background Thrombolytic therapy (TT) has evolved as an alternative to surge ry for prosthetic valve thrombosis (PVT), but its utility in patient manage ment is still debated and the long-term results are not available. Methods From 1990 through 1999, we treated 110 consecutive patients (52 men , mean age 35.4 +/- 10.8 years) of left-sided obstructive PVT (96 mitral, 1 4 aortic) with TT (streptokinase in 108, urokinase in 2) according to a spe cified protocol of prolonged infusion. Serial echo Doppler parameters were monitored in all patients to guide the duration of TT and to quantify its e fficacy. Ninety of the 102 survivors of the index episode were followed vp for a mean period of 31.3 +/- 27.8 months (range 1-112 months). Results Complete hemodynamic response ton cinefluoroscopy and echo Doppler criteria) was seen in 90 (81.8%) episodes, partial response in 11 (10%), an d failure in 9 (8.2%). The mean duration of rr was 42.8 +/- 20.4 hours. Fiv e of the 7 patients who were initially seen in cardiogenic shock/overt pulm onary edema died during therapy. After these patients were excluded, the ra te of complete response did not differ among patients with New York Heart A ssociation class I/II (80%), class III (86.3%), or class IV (81.5%). The re sponse rate also did not vary with the type, position of prosthesis, durati on of symptoms, or time lag since surgery. There were 21 (19.1%) embolic ep isodes during therapy, including 6 strokes. These were significantly more f requent in patients with atrial fibrillation (AF) (odds ratio on multivaria te analysis 2.3, 95% confidence interval 1.3-3.9, P =.01). On follow-vp, th ere were 25 recurrences of PVT, of which 20 again received TT with a comple te response in 14 (70%). At 5 years the actuarial survival was 85.2% and th e event-free survival was 61.5%. The presence of chronic AF was a significa nt predictor of recurrence of PVT (odds ratio 2.2, 95% confidence interval 1.2-3.9, P=.008). Conclusions Tr is effective in the majority of patients with PVT but is ass ociated with a high rate of embolism, especially in patients with AF. Exclu ding patients with cardiogenic shock/overt pulmonary edema tin whom TT is l argely ineffective), the success of TT does not vary with the New York Hear t Association class, duration of symptoms, or other patient variables. The recurrence rates of PVT are high after even successful TT, especially in pa tients with AF.