Management of prosthetic heart valve obstruction: Fibrinolysis versus surgery. Early results and long-term follow-up in a single-centre study of 263 cases

Abstract

Optimal management of prosthetic heart valve obstruction (PHVO) remains controversial even though surgery is usually recommended. To better define the efficacy and safety of fibrinolysis versus surgery in the pre- and post-transoesophageal echocardiography (TEE) eras. We analysed initial results and follow-up data from a large, retrospective, single-centre series, comparing fibrinolysis and surgery in patients with PHVO treated over 20 years. Two hundred and sixty-three consecutive episodes of PHVO in 210 patients, mainly left sided, were managed in our institution by either fibrinolysis (n=127) or surgery (n=136). Early clinical evolution was assessed in terms of haemodynamic success and complications. Concerning early results, there were no significant differences between the two groups in terms of mortality (10%). However, haemodynamic success was significantly more frequent in the surgical group (89% versus 70.9% p<0.001), embolic episodes were significantly more frequent in the fibrinolysis group (15% versus 0.7%, p<0.001), as were total complications (25.2% versus 11.1%, p=0.005). Long-term follow-up, with a mean duration of 6 years (range: 0-20), was obtained and showed significantly better results in the surgical group in terms of recurrence (p=0.021) and mortality (p=0.002). In univariate and multivariable analyses, NYHA functional class at presentation was a strong predictor of late death (p<0.01). Management of patients during the pre- and post-TEE eras was significantly different, since introduction of TEE surgery has become the preferred therapeutic strategy. Results of this extensive single-centre experience indicate that since the introduction of TEE, surgery is more frequently performed than fibrinolysis due to the improvement of thromboembolic risk assessment. Furthermore, prompt surgical treatment is associated with a better early success rate and a significantly lower incidence of complications than fibrinolysis in left-sided PHVO. However, fibrinolysis may be justified in selected cases. Long-term follow-up showed significantly better results in the surgical group in terms of recurrence and mortality.

Prosthetic heart valve obstruction: thrombolysis or surgical treatment?

“…On the other hand, more recent studies show that fibrinolytic therapy can restore adequate function of the thrombosed prosthetic valve with high rates of success and lower mortality and complication rates than those reported by Roudaut et al, 25 mainly in the post-TEE era. On this basis, thrombolysis is recommended as the first-line treatment for all patients with left-sided PVT by the Society for Heart Valve Disease (SHVD) guidelines and for patients with low thrombus burden (<0.8cm 2 ) regardless of functional class by the American College of Chest Physicians (ACCP) guidelines (Table 1).…”

“…Roudaut et al 25 , in the largest single-centre nonrandomized retrospective study, cited better early success rate and a significant lower incidence of complications for postsurgical than post-fibrinolytic therapy in left-sided OPVT. There was no difference between the two groups in terms of mortality (10%).…”

“…Fibrinolysis has a higher chance of being successful if the thrombus is younger than 14 days. 25 Chronic thrombosis resembles a pannus and clinically responds more poorly to thrombolysis. Therefore, a surgical approach might be considered in patients with chronic thrombosis.…”

“…4,22 The drawback of surgery is the high operative mortality (between 5% and 18%) which is largely related to clinical functional class, with New York Heart Association (NYHA) functional class at presentation to be a strong predictor of surgical mortality (4−7% in class I−III vs. 17.5−31.3% in class IV). 3,25 Thrombolysis followed by heparin infusion has been suggested as an alternative to surgery. It is associated with lower mortality rate but carries the risk of systemic embolism, bleeding, and rethrombosis.…”

Mitral Mechanical Prosthetic Valve Thrombosis Four Years After Discontinuing Anticoagulation: A Case Report

“…Lengyel and group advocate thrombolysis as the first line of treatment if there are no contraindications [16] while Roudaut and group, with their experience of over 250 cases, prefer surgery. [17] The 2014 AHA guidelines on Valvular Heart Disease have issued the following recommendations. [6] 1.…”