Fibrinolysis in left-sided mechanical prosthetic valve thrombosis with high INR

Abstract

Background: A significant number of patients with prosthetic valve thrombosis have a prothrombin time international normalised ratio in the therapeutic range at presentation. Surgery may not be possible in many patients and traditionally a high international normalised ratio is considered a relative contraindication for fibrinolysis. Methods: We conducted an observational study in patients with left-sided obstructive prosthetic valve thrombosis with international normalised ratio at or above the therapeutic range at presentation who received fibrinolysis. The fibrinolytic regimens, timing of initiation, success of fibrinolysis, risk of major and minor bleeding and ischaemic stroke were evaluated in the study. Results: Of 30 patients included in the study 70% received immediate fibrinolysis and in 30% it was delayed. The majority of patients (90%) presented with New York Heart Association class III/IV symptoms. The mean international normalised ratio at fibrinolysis was 3.04 ± 0.70 in the immediate group and 2.42 ± 0.89 in the delayed group. Haemodynamically stable patients who had delayed initiation of fibrinolysis had a trend towards less bleeding without an increase in mortality. The rates of intracranial haemorrhage (0% vs. 7.7%), minor bleeding (12.5% vs. 25.1%) and ischaemic stroke (0% vs. 30.7%) were lower in patients who received low dose infusion compared to a conventional dose. Conclusions: Fibrinolysis can be considered in patients with prosthetic valve thrombosis with high international normalised ratio at presentation. For haemodynamically stable patients, delayed initiation of fibrinolysis is associated with a marginally lower bleeding risk without an increase in mortality. Low dose infusion may be considered over a conventional dose as it is associated with a lower incidence of ischaemic stroke and a good rate of valve function restoration with a trend towards less bleeding.

A Prospective Study on Treatment of Prosthetic Valve Thrombosis and its Clinical Presentation

“…The Indian studies have had a slightly higher incidence among men than women, with an average age under 40 [14][15] . Numerous analyses have established that PV thrombosis in mitral valve is two-three times common than aortic prosthesis thrombosis, comparable to this study as the mitral valve was most often intricate in the obstacle [16][17] . The total mortality in our study was 14% and approximately 16% of the overall mortality in the thrombolysis group which is lesser than in the former study in Lahore; though, the rate was somewhat greater than few intercontinental researches where the rate of mortality was about 7% [18][19] .…”

Dual mechanical valve thrombosis resolution through thrombolytics: a case series

“…Two retrospective series have examined thrombolysis safety in patients with elevated INR between 2 and 5 with a low population of dual valve thrombosis and showed low rates of bleeding complications. 16 , 17 The American Heart Association (AHA) guidelines for treatment of mechanical PVT recommend urgent low-dose, slow-infusion thrombolysis or surgery for left-sided mechanical valves with symptoms of obstruction. The AHA guidelines further state that thrombolysis is ‘an acceptable alternative for obstructive PVT patients at high or prohibitive surgical risk or in patients who have a small thrombus burden, mild HF symptoms (NYHA class I or II), and low bleeding risk’, but do not comment on modifications for high bleeding risk patients or dual PVT.…”

Mechanical prosthetic valve thrombosis after ChAdOx1-nCoV-19 vaccination: A case report

“…Low, half dose of STK as a slow infusion can be given for patients with PVT and coagulopathy, and in such patients who are hemodynamically stable, delayed initiation of thrombolysis can be tried. 7 …”