Accelerated Infusion of Streptokinase for the Treatment of Left-Sided Prosthetic Valve Thrombosis

Abstract

Background— No large prospective studies have evaluated the efficacy of fibrinolytic therapy for left-sided prosthetic valve thrombosis, yet it remains the first line of treatment in developing countries. Methods and Results— We performed a randomized controlled trial comparing an accelerated infusion with the conventional infusion of streptokinase in 120 patients with a first episode of left-sided prosthetic valve thrombosis. The primary outcome measure was the occurrence of a complete clinical response, defined as objectively documented complete restoration of valve function in the absence of major complications. The secondary outcome was a composite of death, major bleeding, embolic stroke, or non–central nervous system systemic embolism. Patients were recruited over a 2.5-year period at a single center in India. Complete clinical response occurred in 38 (64.4%) of 59 patients with the accelerated infusion compared with 32 (53.3%) of 60 with the conventional infusion (hazard ratio 1.6, 95% confidence interval 0.9 to 2.5, P =0.055). There was no significant difference in the occurrence of the composite secondary outcome (hazard ratio 1.4, 95% confidence interval 0.5 to 3.5, P =0.50) or major bleeding (hazard ratio 2.2, 95% confidence interval 0.6 to 7.7, P =0.24) with the accelerated infusion. The success rate with fibrinolytic therapy was low overall (59%) and very low in patients in New York Heart Association functional class III/IV (24%). Conclusions— The large number of patients recruited from a single center underscores the massive burden of prosthetic valve thrombosis in developing countries. Fibrinolytic therapy with streptokinase is less efficacious than previously believed. The accelerated streptokinase infusion is not better than the standard infusion for left-sided prosthetic valve thrombosis. Developing countries urgently need more effective strategies to prevent and treat prosthetic valve thrombosis.

Thrombolytic Therapy for the Treatment of Prosthetic Heart Valve Thrombosis in Pregnancy With Low-Dose, Slow Infusion of Tissue-Type Plasminogen Activator

“…In general, TT for the treatment of PVT in nonpregnant patients is successful in ≈85% of patients. [36][37][38][39][40][41][42][43] On the other hand, our protocol demonstrated a complete success rate among all pregnant patients with PVT. This could be explained by the fresh and rapid development of clot in this specific patient population compared with nonpregnant patients with gradually developed and organized thrombus.…”

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

“…Patients with severe MR who develop an EF ≤60% or LVESD ≥40 have already developed LV systolic dysfunction. [112][113][114][115] One study has suggested that for LV function and size to return to normal after mitral valve repair, the left ventricular ejection fraction (LVEF) should be >64% and LVESD <37 mm. 112 Thus, when longitudinal follow-up demonstrates a progressive decrease of EF toward 60% or a progressive increase in LVESD approaching 40 mm, it is reasonable to consider intervention.…”

Prosthetic heart valve obstruction: thrombolysis or surgical treatment?

“…Despite that accelerated protocols are attractive because they might achieve more rapid lysis of the thrombus, they increase the risk of serious bleeding and embolic events. 29 Keeping with this, recent data proposed that low dose of rt-PA (25 mg) and slow infusion (6 hours) resulted in mortality benefit derived from the lower rates of bleeding and systemic thromboembolism. 30 Serial TTE during the infusion allows the reassessment of thrombus resolution.…”