To the Editor:
With great interest we read the article by Kao and colleagues1 regarding thrombosis of a prosthetic tricuspid valve.
We would like to place emphasis on therapeutic choices in the treatment of this serious complication. As is well known, the incidence of thrombosis of mechanical cardiac valves is highest in the tricuspid position (up to 20%),2 due to low pressure in the circuit. Patients with tricuspid valve replacements (who therefore run a high risk of thrombosis) benefit from a therapeutic combination of anticoagulant and antiplatelet agents.
Controversy remains about the better choice of treatment for thrombosis of mechanical cardiac valves—that is, thrombolysis or reoperation. The existing evidence suggests that thrombolysis is associated with low morbidity and mortality rates and that the risk of re-thrombosis is acceptable in cases of left-heart prosthetic thrombosis.3 As Alpert suggests in his editorial comment in the Journal of the American College of Cardiology,4 thrombolysis is the recommended initial treatment for thrombosis of mechanical valves in the right heart.
In our experience, repeated thrombolysis has been successful in resolving 7 episodes of prosthetic thrombosis in a 49-year-old patient who had Ebstein anomaly corrected with a mechanical valve in the tricuspid position.5 The patient continues to be free of symptoms 5 years after her last thrombotic event.
Therefore, we recommend thrombolysis as the treatment of choice in patients who have experienced thrombosis of mechanical cardiac valves, independent of the type and position of the prosthetic valve, the patient's New York Heart Association functional class, or the size of the thrombus.
Fidel Manuel Cáceres-Lóriga, MD, PhD
José Santos-Gracia, MD, PhD
Horacio Pérez-López, MD, PhD
Institute of Cardiology and Cardiovascular Surgery, Vedado, Havana, Cuba
References
- 1.Kao CL, Lu MS, Chang JP, Yang TY, Cheng HW. Thrombotic obstruction of a mechanical prosthetic valve in tricuspid position. Tex Heart Inst J 2009;36(3):261–3. [PMC free article] [PubMed]
- 2.Lengyel M, Horstkotte D, Voller H, Mistiaen WP. Working Group Infection, Thrombosis, Embolism and Bleeding of the Society for Heart Valve Disease. Recommendations for the management of prosthetic valve thrombosis. J Heart Valve Dis 2005;14(5):567–75. [PubMed]
- 3.Nagy A, Denes M, Lengyel M. Predictors of the outcome of thrombolytic therapy in prosthetic mitral valve thrombosis: a study of 62 events. J Heart Valve Dis 2009;18(3):268–75. [PubMed]
- 4.Alpert JS. The thrombosed prosthetic valve: current recommendations based on evidence from the literature. J Am Coll Cardiol 2003;41(4):659–60. [DOI] [PubMed]
- 5.Caceres-Loriga FM, Perez-Lopez H, Santos-Gracia J, Morlans-Hernandez K, Marrero-Mirayaga MA. Thrombolytic treatment as first option in recurrent tricuspid prosthetic valve thrombosis and Ebstein's anomaly. J Pharm Pharm Sci 2005;8(2):332–4. [PubMed]