Thrombolysis is an effective and safe therapy in stuck mitral valves with delayed presentation as well as hemodynamically unstable patients

摘要

Background: Thrombosis is a well-recognized complication ofprosthetic heart valves and is associated with substantial morbidityand mortality. A repeat operation carries a substantial risk, withmortality rate ranging from 10% to 15% in selected series, whichmay be two- to three-fold higher in critically ill patients.Nowadays, there are more than 200 reported cases of thrombolysisof stuck left-sided valves, with an overall 82% initial successrate, 12% thromboembolism, 5–10% stroke, 6% death, 5% majorbleeding and 11% recurrence rate. Bileaflet valves are of special interest because their delicate mechanism may lead more easilyto leaflet immobilization, even with a relatively small clot.Methods: In a prospective observational study, we studied atotal of 34 patients, 10 were male (29.4%) and 24 were female(70.6%). Twenty-four patients were 40 year (29.4%), who experienced one or moreepisodes of stuck bileaflet mitral valve over a 12-month period andreceived thrombolytic therapy with streptokinase as a treatment.And 27 patients (79.4%) were presented within 14 days of symptomsand 7 patients (20.6%) after more than 14 days of symptoms.Functional class at initial episode was New York Heart Association(NYHA) class I–II in 12 patients (35.3%) and NYHA Class III–IVin 22 patients (64.7%), 25 patients (73.5%) were hemodynamicallystable and 9 patients (26.5%) were hemodynamically unstable (i.e.BP < 90mmHg systolic) on presentation.Fluoroscopy was the mainstay of the evaluation of leaflet mobilityand diagnosis of stuck mitral valve. Gradient across the mitralprosthetic valve is used to monitor the success of the thrombolytictherapy every 6 hourly. Fall ofmeangradient more than 50% consideredas successful thrombolysis. Final results were again checkedby fluoroscopy with documentation of improved leaflet mobility.Results: Patients receiving thrombolytic therapy with streptokinaseachieved an overall 82.7% freedom from a repeat operation ormajor complications, a large subcutaneous hematoma occurred inone patient (2.9%), repeat operation required in two patients (5.9%),allergic reaction in one patient (2.9%) and two patient died duringtherapy (5.9%). All patients including those with delayed presentation(more than 14 days) and hemodynamically unstable patientshave good results similar to those who presented within 14 daysand hemodynamically stable patients. Mortality is higher in unstablepatients and reoperation higher with delayed presentation.Conclusion: Thrombolysis with streptokinase is highly successfuland safe therapy In hemodynamically stable as well as unstablepatients, or those with early or delayed presentation with stuckbileaflet mitral valves, especially in centers where cardiothoracicsurgery back up is not very good.