How to perform and manage low-dose and slow/ultra-slow tissue type plasminogen activator infusion regimens in patients with prosthetic valve thrombosis

Excerpt

Over the last two decades, thrombolytic therapy (TT) has become an alternative to surgery as a first-line therapy in patients with thrombosed mechanical valves [1‐3]. In TROIA Trial, low dose (25 mg)—slow infusion (6 h) of tissue type plasminogen activator (t-PA) has been found to be an effective and safe regimen in the management of prosthetic valve thrombosis (PVT) [4]. Accelerated and high dose TT regimens were associated with higher complication and mortality rates. 2014 AHA/ACC guideline for the management of patients with valvular heart disease had recommended emergency surgery for patients with left-sided PVT with NYHA Class III-IV (Class 1-B) and large, mobile thrombus(> 0.8 cm²) (Class 2a). Additionaly, TT was reasonable for patients with a thrombosed left-sided prosthetic heart valve, recent onset (< 14 days) of NYHA class I to II symptoms, and a small thrombus (< 0.8 cm²)(Class 2a) [5]. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease now recommends urgent initial treatment with either slow-infusion low-dose TT or emergency surgery for obstructive PVT as first-line treatment strategies with class 1-B indication [6]. Based on our experience regarding TT [3, 4, 7], low dose and ultra-slow infusion (25 mg/25 h) of the TT regimen could be associated with lower complication rates. Recently, the ultra-slow PROMETEE Trial has demonstrated that ultra-slow (25 h) infusion of low dose (25 mg) t-PA without bolus appears to be associated with quite low non-fatal complications and mortality for PVT patients without loss of effectiveness, except for those with NYHA class-IV [8]. …