Letter to the Editor
Management of prosthetic valve thrombosis in pregnancy
Tratamento da trombose da válvula protética na gravidez
a Department of Cardiology, İskilip Atıf Hoca State Hospital, Çorum, Turkey
b Department of Cardiology, Gaziemir State Hospital, İzmir, Turkey
c Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
d Department of Cardiology, Kars Kafkas University, Faculty of Medicine, Kars, Turkey
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array:4 [ "nombre" => "Macit" "apellidos" => "Kalçık" "email" => array:1 [ 0 => "macitkalcik@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff1" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Mustafa" "apellidos" => "Ozan Gürsoy" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Sabahattin" "apellidos" => "Gündüz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Mehmet" "apellidos" => "Özkan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Department of Cardiology, İskilip Atıf Hoca State Hospital, Çorum, Turkey" "etiqueta" => "a" "identificador" => "aff1" ] 1 => array:3 [ "entidad" => "Department of Cardiology, Gaziemir State Hospital, İzmir, Turkey" "etiqueta" => "b" "identificador" => "aff0005" ] 2 => array:3 [ "entidad" => "Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Cardiology, Kars Kafkas University, Faculty of Medicine, Kars, Turkey" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Tratamento da trombose da válvula protética na gravidez" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the article by Cardoso et al. which was recently published in the <span class="elsevierStyleItalic">Journal</span>.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> We thank the authors for the contribution of their report describing thrombolytic therapy (TT) with streptokinase (SK) in a pregnant patient with prosthetic valve thrombosis (PVT). At the same time, we want to make some important points regarding major issues with patient management and TT regimens for PVT in pregnancy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Pregnancy is a highly thrombogenic state which poses an increased risk of thrombosis in women with mechanical prosthetic valves. PVT in pregnancy is potentially life-threatening for both mother and fetus and management strategies are the subject of debate. Common available treatment modalities for this serious complication include optimized anticoagulation, TT<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2–5</span></a> and surgery,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> each with its pros and cons.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Surgery is suggested as a first-line strategy in most cases with left-sided PVT; however, TT has recently been used with successful outcomes.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2–5</span></a> We have recently reported that low dose (25 mg) and slow infusion (six hours) of tissue-type plasminogen activator (t-PA) is the safest TT regimen for PVT without compromising effectiveness as compared with higher doses and rapid infusions of SK or tPA.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> The TROIA trial showed that tPA was superior to SK in terms of success and complication rates, and accelerated TT regimens (either tPA or SK) were associated with higher mortality and complication rates. However, due to the higher costs of tPA treatment, SK is still widely used for TT in developing countries.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Although no evidence-based guidelines for pregnant patients complicated with PVT are currently available, recommendations for this complication are similar to those for the management of PVT in non-pregnant patients; definitive class I recommendations are lacking due to the absence of randomized controlled trials. We have previously reported that low dose (25 mg) and slow infusion (six hours) of t-PA without bolus under the guidance of serial transesophageal echocardiography (TEE) is very safe and associated with very high thrombolytic success in pregnant patients with PVT.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> In this single-center prospective study including a relatively large number of pregnant patients with PVT, this strategy was associated with successful thrombolysis in all patients, with lower maternal and fetal adverse events compared with surgery or anticoagulation based on the available published data.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The lack of TEE guidance during TT is another drawback of the current report. Although transthoracic echocardiography (TTE) is an essential part of the diagnostic assessment of a patient with PVT, its value is usually limited because of a certain degree of acoustic shadowing and characteristic reverberations caused by the prosthetic material itself. On the other hand TEE, with its high resolution, has indispensable value to assess thrombus size, mobility and location, which may help in decision-making regarding thrombolysis, anticoagulation and surgery.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7,8</span></a> Moreover, TEE provides direct imaging of thrombus in the left atrium or the left atrial appendage, which usually cannot be detected with TTE. The presence of a left atrial thrombus is accepted as a contraindication for thrombolysis and should be ruled out by TEE before TT. Finally, the reduction of thrombus burden and need for additional TT sessions can be evaluated only by TEE. A non-obstructive residual thrombus after the first TT session cannot be diagnosed without TEE.</p><p id="par0030" class="elsevierStylePara elsevierViewall">As a result, we can conclude that TT with low-dose (25 mg) slow infusion (six hours) of tPA should be considered as the first-line therapy for pregnant PVT patients unless contraindicated, since cardiac surgery exposes mother and the fetus to a greater risk than does TT.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> Serial TEE guidance should complement TTE in every step of the management algorithm in patients undergoing TT for PVT.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prosthetic mitral valve thrombosis in pregnancy: from thrombolysis to anticoagulation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G. 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Alon" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Obstet Gynecol" "fecha" => "1998" "volumen" => "179" "paginaInicial" => "1643" "paginaFinal" => "1653" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9855611" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003400000009/v1_201509130054/S2174204915001920/v1_201509130054/en/main.assets" "Apartado" => array:4 [ "identificador" => "29282" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003400000009/v1_201509130054/S2174204915001920/v1_201509130054/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204915001920?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 5 | 11 |
| 2024 October | 42 | 27 | 69 |
| 2024 September | 40 | 24 | 64 |
| 2024 August | 40 | 25 | 65 |
| 2024 July | 28 | 30 | 58 |
| 2024 June | 41 | 33 | 74 |
| 2024 May | 25 | 19 | 44 |
| 2024 April | 27 | 25 | 52 |
| 2024 March | 33 | 31 | 64 |
| 2024 February | 25 | 46 | 71 |
| 2024 January | 21 | 34 | 55 |
| 2023 December | 22 | 28 | 50 |
| 2023 November | 19 | 18 | 37 |
| 2023 October | 16 | 14 | 30 |
| 2023 September | 22 | 25 | 47 |
| 2023 August | 18 | 16 | 34 |
| 2023 July | 17 | 7 | 24 |
| 2023 June | 20 | 21 | 41 |
| 2023 May | 31 | 14 | 45 |
| 2023 April | 24 | 8 | 32 |
| 2023 March | 24 | 19 | 43 |
| 2023 February | 30 | 23 | 53 |
| 2023 January | 23 | 12 | 35 |
| 2022 December | 29 | 19 | 48 |
| 2022 November | 49 | 27 | 76 |
| 2022 October | 13 | 16 | 29 |
| 2022 September | 24 | 26 | 50 |
| 2022 August | 32 | 29 | 61 |
| 2022 July | 25 | 30 | 55 |
| 2022 June | 20 | 24 | 44 |
| 2022 May | 26 | 32 | 58 |
| 2022 April | 28 | 26 | 54 |
| 2022 March | 37 | 26 | 63 |
| 2022 February | 25 | 22 | 47 |
| 2022 January | 18 | 11 | 29 |
| 2021 December | 22 | 27 | 49 |
| 2021 November | 38 | 43 | 81 |
| 2021 October | 95 | 47 | 142 |
| 2021 September | 44 | 30 | 74 |
| 2021 August | 58 | 33 | 91 |
| 2021 July | 28 | 24 | 52 |
| 2021 June | 14 | 20 | 34 |
| 2021 May | 57 | 41 | 98 |
| 2021 April | 43 | 37 | 80 |
| 2021 March | 59 | 12 | 71 |
| 2021 February | 53 | 23 | 76 |
| 2021 January | 17 | 10 | 27 |
| 2020 December | 27 | 7 | 34 |
| 2020 November | 31 | 9 | 40 |
| 2020 October | 15 | 6 | 21 |
| 2020 September | 38 | 10 | 48 |
| 2020 August | 20 | 6 | 26 |
| 2020 July | 36 | 10 | 46 |
| 2020 June | 20 | 17 | 37 |
| 2020 May | 33 | 4 | 37 |
| 2020 April | 30 | 9 | 39 |
| 2020 March | 29 | 13 | 42 |
| 2020 February | 39 | 15 | 54 |
| 2020 January | 18 | 5 | 23 |
| 2019 December | 35 | 3 | 38 |
| 2019 November | 18 | 4 | 22 |
| 2019 October | 15 | 7 | 22 |
| 2019 September | 29 | 8 | 37 |
| 2019 August | 13 | 5 | 18 |
| 2019 July | 33 | 14 | 47 |
| 2019 June | 26 | 12 | 38 |
| 2019 May | 29 | 14 | 43 |
| 2019 April | 20 | 10 | 30 |
| 2019 March | 36 | 8 | 44 |
| 2019 February | 68 | 8 | 76 |
| 2019 January | 32 | 4 | 36 |
| 2018 December | 52 | 9 | 61 |
| 2018 November | 109 | 12 | 121 |
| 2018 October | 232 | 19 | 251 |
| 2018 September | 51 | 7 | 58 |
| 2018 August | 94 | 8 | 102 |
| 2018 July | 26 | 3 | 29 |
| 2018 June | 35 | 8 | 43 |
| 2018 May | 53 | 4 | 57 |
| 2018 April | 46 | 3 | 49 |
| 2018 March | 59 | 9 | 68 |
| 2018 February | 16 | 7 | 23 |
| 2018 January | 27 | 4 | 31 |
| 2017 December | 28 | 9 | 37 |
| 2017 November | 20 | 12 | 32 |
| 2017 October | 17 | 14 | 31 |
| 2017 September | 11 | 15 | 26 |
| 2017 August | 30 | 17 | 47 |
| 2017 July | 16 | 9 | 25 |
| 2017 June | 24 | 29 | 53 |
| 2017 May | 31 | 20 | 51 |
| 2017 April | 25 | 4 | 29 |
| 2017 March | 29 | 34 | 63 |
| 2017 February | 24 | 4 | 28 |
| 2017 January | 25 | 3 | 28 |
| 2016 December | 22 | 9 | 31 |
| 2016 November | 13 | 2 | 15 |
| 2016 October | 28 | 10 | 38 |
| 2016 September | 19 | 4 | 23 |
| 2016 August | 8 | 2 | 10 |
| 2016 July | 10 | 3 | 13 |
| 2016 June | 13 | 5 | 18 |
| 2016 May | 20 | 3 | 23 |
| 2016 April | 19 | 9 | 28 |
| 2016 March | 24 | 10 | 34 |
| 2016 February | 35 | 15 | 50 |
| 2016 January | 39 | 13 | 52 |
| 2015 December | 42 | 9 | 51 |
| 2015 November | 33 | 11 | 44 |
| 2015 October | 43 | 31 | 74 |
| 2015 September | 54 | 13 | 67 |
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