Thrombolytic Therapy for the Treatment of Prosthetic Heart Valve Thrombosis in Pregnancy With Low-Dose, Slow Infusion of Tissue-Type Plasminogen Activator

Aug 19, 2013
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Authors:
Özkan M, Çakal B, Karakoyun S, et al.
Citation:
Circulation 2013;128:532-540.
Summary By:
David S. Bach, MD, FACC

Study Questions:

What are the safety and efficacy of low-dose (25 mg), slow infusion (6 hours) tissue-type plasminogen activator (tPA) for the treatment of prosthetic heart valve (PHV) thrombosis in pregnant women?

Methods:

Between 2004 and 2012, tPA was administered under transesophageal echocardiography (TEE) guidance to 24 consecutive women in 25 pregnancies with 28 PHV thrombosis episodes (obstructive in 15, nonobstructive in 13). Mean age of the patients was 29 ± 6 years.

Results:

The mean dose of tPA was 49 ± 30 mg (range 25-100 mg). All episodes resulted in complete lysis of thrombus after thrombolytic therapy. One patient had placental hemorrhage with preterm live birth at the 30th week, and one patient had minor bleeding.

Conclusions:

Low-dose, slow infusion of tPA with repeated doses as needed is an effective therapy with an excellent thrombolytic success for the treatment of PHV thrombosis in pregnant women. The authors concluded that this protocol also seemed to be safer than cardiac surgery or alternative medical strategies published to date, and that thrombolytic therapy should be considered first-line therapy in pregnant patients with PHV thrombosis.

Perspective:

PHV thrombosis is rare; however, pro-coagulant changes in the hemostatic system during pregnancy increase its rate of occurrence. PHV thrombosis during pregnancy is life-threatening for both mother and fetus. Cardiac surgery during pregnancy has been associated with high risks of maternal and fetal mortality and morbidity, and the optimal treatment of this complication has been unclear. This report describes a high rate of success and low rate of complications associated with TEE-guided low-dose, slow administration of tPA, suggesting that this might be a reasonable first-line treatment for this relatively rare complication.

Keywords: Heart Valve Prosthesis, Thrombolytic Therapy, Morbidity, Live Birth, Fibrinolytic Agents, Thrombosis, Fetus, Heart Valve Diseases, Cardiac Surgical Procedures, Fetal Mortality, Tissue Plasminogen Activator, Heart Valves, Hemorrhage, Pregnancy, Echocardiography


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