Management of Obstructive Prosthetic Heart Valve Thrombosis: Thrombolytic Therapy or Anticoagulation?

To the Editor:

We have read with great interest the article by Llopis Gisbert et al, entitled “Bioprosthetic Valve Thrombosis and Obstruction Secondary to COVID-19.” We appreciate the authors for their case reports describing the successful management of prosthetic valve thrombosis (PVT) secondary to COVID-19. However, we believe that there are several major drawbacks that need to be addressed.

First of all, during the past 2 decades, thrombolytic therapy (TT) has increasingly become an alternative to surgery as first-line therapy in patients with obstructive PVT. Ozkan et al. reported on the safety and efficacy of TT regimens with low-dose and slow-infusion tissue-plasminogen activator. The 2020 American College of Cardiology/American Heart Association (ACC/AHA) 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 IB indications. The most obvious problem with this case report is in the abstract, where it states that anticoagulation is preferred, although guideline recommendations for major cardiovascular TT are clear. Perhaps the authors can explain the reasons for not applying TT or surgical therapy.

Second, one of the treatment options for PVT is intensive anticoagulation. The effectiveness of anticoagulation in the treatment of PVT was based on data from a limited number of publications. It has been reported that the prognosis for a small asymptomatic thrombus (length < 10 mm) is favourable with optimization of anticoagulant therapy. , Recently, we reported that the success rate of anticoagulation therapy containing heparin in patients with PVT was 46.8%. Readers may wonder why anticoagulation with the low rate of success was preferred to the treatment of PVT over TT, the effectiveness and safety of which has been proved by numerous studies.

Funding Sources

The authors report no funding sources relevant to the contents of this paper.

Disclosures

The authors have no conflicts of interest to disclose.