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

Abstract

P regnancy is associated with increased risk of thrombosis among women with mechanical prosthetic heart valves. 1 The largest literature review of women with a prosthetic heart valve who were on anticoagulation during pregnancy reported that thromboembolic complications occurred in 3.9% of women taking only warfarin, 9.2% of women who received unfractionated heparin in the first trimester followed by warfarin, and one fourth of women treated with unfractionated heparin throughout their pregnancy. Maternal death was observed in these groups in 2%, 4%, and 15%, respectively, and was usually related to prosthetic valve thrombosis (PVT).2 Similarly, 15% of pregnant women developed PVT while using low-molecular-weight heparin. The guidelines suggest optimizing anticoagulation in noncritically ill patients with recent subtherapeutic anticoagulation. Surgery is recommended when anticoagulation fails, for critically ill patients with obstructive thrombosis, or for patients with large (≥10 mm) nonobstructive PVT complicated by embolism. Fibrinolysis is recommended for either critically ill patients when Background-Prosthetic valve thrombosis during pregnancy is life-threatening for mother and fetus, and the treatment of this complication is unclear. Cardiac surgery in pregnancy is associated with very high maternal and fetal mortality and morbidity. Thrombolytic therapy has rarely been used in these patients. The aim of this study is to evaluate the safety and efficacy of low-dose (25 mg), slow infusion (6 hours) of tissue-type plasminogen activator for the treatment of prosthetic valve thrombosis in pregnant women. Methods and Results-Between 2004 and 2012, tissue-type plasminogen activator was administered to 24 consecutive women in 25 pregnancies with 28 prosthetic valve thrombosis episodes (obstructive, n=15; nonobstructive, n=13). Mean age of the patients was 29±6 years. Thrombolytic therapy sessions were performed under transesophageal echocardiography guidance. The mean dose of tissue-type plasminogen activator used was 48.7±29.5 mg (range, 25-100 mg). All episodes resulted in complete thrombus lysis after thrombolytic therapy. One patient had placental hemorrhage with preterm live birth at the 30th week, and 1 patient had minor bleeding. Conclusions-Low-dose, slow infusion of tissue-type plasminogen activator with repeated doses as needed is an effective therapy with an excellent thrombolytic success rate for the treatment of prosthetic valve thrombosis in pregnant women. This protocol also seems to be safer than cardiac surgery or any alternative medical strategies published to date. Thrombolytic therapy should be considered first-line therapy in pregnant patients with prosthetic valve thrombosis.

Successful thrombolysis of aortic prosthetic valve thrombosis during first trimester of pregnancy

“…6,9 This is almost similar to that (85%) in non-pregnant patients with PVT. 2 Overall complication rate is 18% (14% major and 32% minor), maternal mortality rate is 5.6-10% and fetal/neonatal mortality is 8-20%. 2,6,9 Clinical success correlated with NYHA class, with best prognosis with class I (success rate 100%) and worst with class IV (65.2%).…”

“…1,7 PVT during pregnancy requires immediate therapy such as valve replacement, thrombolysis or surgical thrombectomy. 2 Guidelines recommend management strategy for PVT in these patients similar to that in non-pregnant ones. 2, 4 Optimization of anticoagulation in non-critically ill patients with recent sub-therapeutic anticoagulation is recommended.…”

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.…”

Delineation of a Giant Thrombus on a Prosthetic Mitral Valve Successfully Thrombolysed with Low Dose Slow Infusion of Tissue Plasminogen Activator

“…A subsequently performed real-time threedimensional (RT3D) TEE clearly demonstrated the presence of a huge thrombus with two mobile components moving up and down during systole ( Figure 2C) and diastole ( Figure 2D). Thrombolytic therapy (TT) with slow-infusion (6 hours) of low dose (25 mg) tissue plasminogen activator (tPA) was administered according to our protocol reported previously (1,2) . TTE revealed a decreased mitral transvalvular gradient of 14/6 mmHg with an increased mitral valve area of 2.5 cm 2 ( Figure 1B).…”