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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=> "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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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 6 | 7 | 13 |
| 2024 Outubro | 35 | 34 | 69 |
| 2024 Setembro | 51 | 40 | 91 |
| 2024 Agosto | 33 | 27 | 60 |
| 2024 Julho | 41 | 32 | 73 |
| 2024 Junho | 40 | 30 | 70 |
| 2024 Maio | 33 | 13 | 46 |
| 2024 Abril | 39 | 26 | 65 |
| 2024 Maro | 36 | 26 | 62 |
| 2024 Fevereiro | 32 | 32 | 64 |
| 2024 Janeiro | 20 | 33 | 53 |
| 2023 Dezembro | 27 | 18 | 45 |
| 2023 Novembro | 35 | 19 | 54 |
| 2023 Outubro | 55 | 15 | 70 |
| 2023 Setembro | 49 | 21 | 70 |
| 2023 Agosto | 35 | 25 | 60 |
| 2023 Julho | 18 | 15 | 33 |
| 2023 Junho | 31 | 13 | 44 |
| 2023 Maio | 37 | 26 | 63 |
| 2023 Abril | 24 | 6 | 30 |
| 2023 Maro | 39 | 23 | 62 |
| 2023 Fevereiro | 27 | 26 | 53 |
| 2023 Janeiro | 20 | 10 | 30 |
| 2022 Dezembro | 39 | 24 | 63 |
| 2022 Novembro | 40 | 26 | 66 |
| 2022 Outubro | 36 | 23 | 59 |
| 2022 Setembro | 24 | 21 | 45 |
| 2022 Agosto | 33 | 33 | 66 |
| 2022 Julho | 32 | 40 | 72 |
| 2022 Junho | 15 | 18 | 33 |
| 2022 Maio | 17 | 34 | 51 |
| 2022 Abril | 34 | 28 | 62 |
| 2022 Maro | 28 | 22 | 50 |
| 2022 Fevereiro | 24 | 29 | 53 |
| 2022 Janeiro | 26 | 28 | 54 |
| 2021 Dezembro | 16 | 28 | 44 |
| 2021 Novembro | 40 | 36 | 76 |
| 2021 Outubro | 38 | 38 | 76 |
| 2021 Setembro | 21 | 27 | 48 |
| 2021 Agosto | 29 | 29 | 58 |
| 2021 Julho | 25 | 19 | 44 |
| 2021 Junho | 20 | 16 | 36 |
| 2021 Maio | 32 | 32 | 64 |
| 2021 Abril | 81 | 50 | 131 |
| 2021 Maro | 52 | 13 | 65 |
| 2021 Fevereiro | 76 | 13 | 89 |
| 2021 Janeiro | 29 | 9 | 38 |
| 2020 Dezembro | 27 | 12 | 39 |
| 2020 Novembro | 41 | 20 | 61 |
| 2020 Outubro | 16 | 6 | 22 |
| 2020 Setembro | 51 | 10 | 61 |
| 2020 Agosto | 12 | 10 | 22 |
| 2020 Julho | 59 | 15 | 74 |
| 2020 Junho | 35 | 12 | 47 |
| 2020 Maio | 40 | 8 | 48 |
| 2020 Abril | 38 | 13 | 51 |
| 2020 Maro | 58 | 13 | 71 |
| 2020 Fevereiro | 46 | 20 | 66 |
| 2020 Janeiro | 22 | 2 | 24 |
| 2019 Dezembro | 32 | 3 | 35 |
| 2019 Novembro | 29 | 5 | 34 |
| 2019 Outubro | 31 | 4 | 35 |
| 2019 Setembro | 30 | 7 | 37 |
| 2019 Agosto | 37 | 6 | 43 |
| 2019 Julho | 42 | 9 | 51 |
| 2019 Junho | 25 | 6 | 31 |
| 2019 Maio | 37 | 9 | 46 |
| 2019 Abril | 17 | 11 | 28 |
| 2019 Maro | 29 | 7 | 36 |
| 2019 Fevereiro | 58 | 12 | 70 |
| 2019 Janeiro | 20 | 5 | 25 |
| 2018 Dezembro | 18 | 11 | 29 |
| 2018 Novembro | 58 | 6 | 64 |
| 2018 Outubro | 103 | 20 | 123 |
| 2018 Setembro | 42 | 7 | 49 |
| 2018 Agosto | 27 | 14 | 41 |
| 2018 Julho | 20 | 7 | 27 |
| 2018 Junho | 38 | 10 | 48 |
| 2018 Maio | 66 | 11 | 77 |
| 2018 Abril | 43 | 4 | 47 |
| 2018 Maro | 76 | 13 | 89 |
| 2018 Fevereiro | 30 | 3 | 33 |
| 2018 Janeiro | 28 | 7 | 35 |
| 2017 Dezembro | 55 | 7 | 62 |
| 2017 Novembro | 35 | 8 | 43 |
| 2017 Outubro | 27 | 9 | 36 |
| 2017 Setembro | 36 | 11 | 47 |
| 2017 Agosto | 38 | 14 | 52 |
| 2017 Julho | 25 | 9 | 34 |
| 2017 Junho | 43 | 12 | 55 |
| 2017 Maio | 45 | 12 | 57 |
| 2017 Abril | 23 | 4 | 27 |
| 2017 Maro | 21 | 9 | 30 |
| 2017 Fevereiro | 15 | 6 | 21 |
| 2017 Janeiro | 26 | 7 | 33 |
| 2016 Dezembro | 24 | 7 | 31 |
| 2016 Novembro | 14 | 3 | 17 |
| 2016 Outubro | 10 | 12 | 22 |
| 2016 Setembro | 32 | 5 | 37 |
| 2016 Agosto | 14 | 0 | 14 |
| 2016 Julho | 7 | 2 | 9 |
| 2016 Junho | 1 | 5 | 6 |
| 2016 Maio | 5 | 10 | 15 |
| 2016 Abril | 24 | 2 | 26 |
| 2016 Maro | 24 | 3 | 27 |
| 2016 Fevereiro | 38 | 20 | 58 |
| 2016 Janeiro | 26 | 7 | 33 |
| 2015 Dezembro | 37 | 13 | 50 |
| 2015 Novembro | 42 | 19 | 61 |
| 2015 Outubro | 96 | 45 | 141 |
| 2015 Setembro | 141 | 80 | 221 |
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