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Ischemic stroke in the course of thrombolytic treatment of prosthetic valve thrombosis: thrombolysis is suggested/Protez kapak trombozunun trombolitik tedavisi sirasinda iskemik inme: Tromboliz onerilir.

Dear Editor,

We have read with great interest the excellent report Ozkan et al. (1). This woman of 25 years old with diagnosis of prosthetic valve thrombosis (PVT) received thrombolytic therapy-low-dose and prolonged infusion of tissue-type plasminogen activator (tPA). After the two hours the infusion was finished and was diagnosed and checked for cerebral computed tomography (CT) scan a cerebral embolism as a complication. Thrombolytic treatment was continued. The final result was successful for both (PVT and ischemic stroke).

We should make some considerations

The PVT is a serious complication of cardiac valve replacement because it is dangerous in the sick person's life. The initial therapeutic decision must be immediate. Currently, the initial therapeutic decision is difficult and controversial. Clinical practice guidelines express no uniform opinions. The European Society of Cardiology proposed surgery as the initial treatment, regardless of clinical status and the size of the thrombus. The Society of Heart Valve Disease recommends that the first choice be thrombolysis in all cases of PVT, unless such treatment is contraindicated. The American Heart Association and American College of Cardiology reserve thrombolysis only for patients with nonobstructive PVT and hemodynamic stability. The American College of Chest Physicians recommends that the main criterion in the therapeutic decision be the size of thrombus, indicating thrombolysis as the treatment choice if the thrombus has an area of +0.8 [cm.sup.2] and surgery in older thrombi. On the basis of the evidence displayed in many studies and our experience over more 20 years, our working group suggests that continuing the search for the best therapy for PVT is no longer necessary. Two therapeutic alternatives exist for managing these severe patients (thrombolytic therapy and surgery), but they are complementary. We propose thrombolysis as the initial treatment if no contraindications are present (e.g., thrombi + 10 mm). Surgery is reserved for patients with contraindications to thrombolysis, those in whom this therapy is unsuccessful, and per se, who present with stroke and left atrial thrombus (2).

The main related limitation with the thrombolytic treatment is when the cerebral embolism occurs. An interesting option to treat this complication during the thrombolytic treatment in the PVT is the thrombolysis continuity as it has reported in this case for Ozkan et al. (1).

In the year 2004, Lengyel et al. (3) indicated that twenty cases of non-hemorrhagic stroke or transient ischemic attack have been treated with thrombolysis, with only one hemorrhagic transformation.

In the year 2005 were published the guidelines of the Society of Heart Valves Disease for the management of PVT and recommend as an indication Class III the thrombolysis in presence of ischemic stroke documented for cerebral CT scan before the 4 hours that initiate the symptoms (4).

We suggest that the thrombolytic therapy in the ischemic stroke can be effective in the first 3 hours of the beginning of symptoms if the cerebral scan do not show signs of hemorrhages. It is generally recommended to interrupt thrombolysis for PHVT if there is clinical evidence of a cerebrovascular accident during treatment, and to perform an urgent cranial CT scan to differentiate between a hemorrhagic and ischemic origin. If there is no evidence of brain hemorrhage on CT scan, thrombolytic therapy can be restarted (5).


(1.) Ozkan M, Gursoy OM, Atasoy B, Uslu Z. Management of acute ischemic stroke occurred during thrombolytic treatment of a patient with prosthetic mitral valve thrombosis: continuing thrombolysis on top of thrombolysis. Anadolu Kardiyol Derg 2012; 12: 689-90.

(2.) Caceres-Lariga FM, Santos-Gracias J, Perez-Lopez H. Thrombolysis versus reoperation in the management of prosthetic valve thrombosis. Am J Cardiol 2011; 108: 753. [CrossRef]

(3.) Lengyel M. Management of prosthetic valve thrombosis. J Heart Valve Dis 2004; 13: 329-34.

(4.) 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: 567-75.

(5.) Caceres-Lariga FM, Perez-Lopez H, Santos-Gracia J, MorlansHernandez K. Prosthetic heart valve thrombosis: pathogenesis, diagnosis and management. Int J Cardiol 2006; 110: 1-6. [CrossRef]

Fidel Manuel Caceres-Loriga

Department of Cardiology, Institute of Cardiology and

Cardiovascular Surgery, Havana-Cuba

Address for Correspondence/Yazisma Adresi: Fidel Manuel Caceres-Loriga, MD, Department of Cardiology, Institute of Cardiology and Cardiovascular Surgery, Havana-Cuba Phone:5378360824 E-mail:

Available Online Date/Cevrimici Yayin Tarihi: 21.02.2013

doi: 10.5152/akd.2013.085

Author Reply

Dear Author,

Thank you very much for your comprehensive and encouraging comments on our article published in "letter to editor" section of Anatolian Journal of Cardiology that I was entirely agree and feel nothing to add on top of it.

Mehmet Ozkan

Clinic of Cardiology, Kartal Kosuyolu Yuksek Ihtisas Education and

Research Hospital, Istanbul-Turkey

Address for Correspondence/Yazisma Adresi: Dr. Mehmet Ozkan, Kartal Kosuyolu Yuksek Ihtisas Egitim ve Arastirma Hastanesi, Kardiyoloji Klinigi, Istanbul-Turkiye Phone: +90 532 255 15 13 Fax: +90 216 459 63 21 E-mail:

Available Online Date/Cevrimici Yayin Tarihi: 21.02.2013
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Article Details
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Author:Caceres-Loriga, Fidel Manuel
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Article Type:Letter to the editor
Date:May 1, 2013
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