Prosthetic valve thrombosis (PVT) is a serious complication that threatens the lives of patients with prosthetic heart valves. The first report by Luluaga et al in 1971 of the effective implementation of thrombolysis in a thrombosed prosthetic valve in tricuspid position started a lengthy and diverse debate in search of the best therapeutic option for PVT. This controversy persists to this day. We read with great interest the report by Keuleers et al on 18 patients who underwent urgent surgery, with 2 deaths in the immediate perioperative phase and 2 recurrences of PVT (11%) in a follow-up period of 76 months. Of 13 patients treated with thrombolysis, there was immediate clinical improvement after a single administration of recombinant tissue plasminogen activator in 12 (92%), of whom 8 (61%) showed complete response, with normalization of echocardiographic findings. Complications in the thrombolytic group included 1 stroke, 1 transient ischemic attack, 1 hemorrhagic complication requiring surgery, and 2 peripheral embolic events with spontaneous resolution. The investigators concluded that thrombolysis is an attractive first-line therapy for patients with PVT, with clinical outcomes comparing favorably to the standard surgical approach.

Recently, Ermis et al compared the results of thrombolysis and surgery in the treatment of obstructive PVT. In assessing the effectiveness of the 2 forms of therapy, there were no statistically significant differences in complete response to treatment, the incidence of cerebral embolism, or the occurrence of bleeding in the central nervous system. Mortality and rethrombosis were similar in the 2 groups. They concluded that fibrinolytic therapy is generally recommended for the treatment of PVT for specific patient groups. These results suggest that it may be as efficacious and safe as surgery.

In our experience of a series of 68 patients with diagnoses of PVT treated with thrombolysis, therapy succeeded in 62 patients (91%) and failed in 6 (9%). In patients with major hemodynamic instability, the success rate was 89% (32 of 36 patients). Systemic embolism occurred in 5 patients (3 cerebral and 2 peripheral). We used intravenous recombinant streptokinase (250,000 IU/30 min and continuous infusion at 100,000 IU/hour, up to 72 hours). This approach also appears to be the most widely used and recommended protocol.

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 ² and surgery in older thrombi.

On the basis of the evidence displayed in many studies and our experience over >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 those who present with stroke and left atrial thrombus.