Ultraslow thrombolytic therapy: A novel strategy in the management of PROsthetic MEchanical valve Thrombosis and the prEdictors of outcomE: The Ultra-slow PROMETEE trial

Management of Patients With Prosthetic Valve Thrombosis After Failed Thrombolytic Therapy

“…Hence, TEE should play a central role in every step of management in patients with PVT, including the initial diagnosis, guidance of therapy, evaluation of the outcome, and identification of patients who are at high risk of adverse events.In the current study, the authors report 31 eligible patients of 122 patients undergoing TT. This means a 74.6% TT success rate at most, which is relatively low compared with current evidence(2)(3)(4)(5).This may be caused by the type of TT agents or protocols used in the current study. We have serial TEE was superior to faster infusion and/or higher dose protocols or streptokinase(2).…”

“…Although we appreciate the authors' work because they specify important data regarding the follow-up of PVT patients after TT for the first time, there remain some major drawbacks to be addressed.The statement that about one-third of the patients treated with TT do not have successful restoration of valve function is not comparable with the most recent evidence reporting success rates of >85% in patients with PVT(2)(3)(4)(5). Moreover, they argue that surgery is more effective than TT, which contradicts the datareported in the most recent meta-analysis by Castilho et al (5).…”

Obstructive Prosthetic Mitral Valve Thrombosis Successfully Thrombolysed with Low-Dose Ultra-Slow Infusion of Tissue Plasminogen Activator

“…the treatment of choice for mechanical valve obstruction was surgery until 1990s. over the last decade, tt has been increasingly used and has become an alternative to surgery as the first line of therapy in patients with thrombosed mechanical valves [1][2][3][4] .…”

“…Guidelines lack definitive class I recommendations due to lack of randomised controlled trials, and usually leave the choice of treatment to the clinician's experience. surgery is suggested as a first line strategy in most situations of left sided PVT; however, tt has been recently used with successful outcomes [1][2][3] . this report describes a patient with giant thrombus located on the prosthetic mitral valve, which was succesfully treated with ultraslow infusion (25 hours) of low dose (25 mg) tissue plasminogen activator (tpA) under the guidance of two-dimensional (2d) and real-time three-dimensional (rt-3d) transesophageal echocardiography (TEE) and fluoroscopy.…”

“…there was no contra-indication for tt and tt was therefore immediately started after taking informed concent of the patient. the tt protocol consisted of repeated sessions of low-dose (25 mg), ultra-slow infusion (25 hours) of tpA without bolus and six hours of heparin infusion between the sessions as reported previously 3 . After the first TT session TTE revealed a minimal decrease in transvalvular gradients of 24/13 mmHg with an increased mitral valve area of 1.1 cm 2 .…”